Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 95003281 | CA |
NPI | 1013388842 |
---|---|
Provider Name | Genevieve Wong |
First Address | Rancho Palos Verdes, CA 90275-5084 |
Second Address | Santa Monica, CA 90401-1328 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2015 |
Last Update Date | 20/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
95003281 | CA NURSE PRACTITIONER LICENSE NUMBER (01) | CA |
95062564 | CA REGISTERED NURSE LICENSE NUMBER (01) | CA |