Provider Demographics
NPI:1174319552
Name:LE PHAM, MAI NICOLE
Entity type:Individual
Prefix:
First Name:MAI NICOLE
Middle Name:
Last Name:LE PHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:THI
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2712 SW 96TH CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6736
Mailing Address - Country:US
Mailing Address - Phone:918-360-5437
Mailing Address - Fax:
Practice Address - Street 1:411 NW 7TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-2810
Practice Address - Country:US
Practice Address - Phone:405-413-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK218733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily