Basic Information
Provider Information | |||||||||
NPI: | 1730683459 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRUONG | ||||||||
FirstName: | LILY | ||||||||
MiddleName: | LY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3516 CANAL ST | ||||||||
Address2: |   | ||||||||
City: | NEW ORLEANS | ||||||||
State: | LA | ||||||||
PostalCode: | 701196109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5049529041 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1542 TULANE AVE RM 231 | ||||||||
Address2: |   | ||||||||
City: | NEW ORLEANS | ||||||||
State: | LA | ||||||||
PostalCode: | 701122865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5045686004 | ||||||||
FaxNumber: | 5045686006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2018 | ||||||||
LastUpdateDate: | 07/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 308989 | LA | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 308989 | 01 | LA | MEDICAL LICENSE NUMBER | OTHER |