Provider Demographics
NPI:1700655396
Name:PHAM, IVY (LACUPUNCTURIST)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:LACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S IVY AVE # 2086
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2835
Mailing Address - Country:US
Mailing Address - Phone:626-740-7546
Mailing Address - Fax:
Practice Address - Street 1:1310 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-4151
Practice Address - Country:US
Practice Address - Phone:626-740-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-25
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19782171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist