Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 22572 | CA |
NPI | 1023409513 |
---|---|
Provider Name | Audrey Fong |
First Address | Palo Alto, CA 94303-3341 |
Second Address | Palo Alto, CA 94304-1601 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2015 |
Last Update Date | 17/08/2016 |