Healthcare Provider Details

I. General information

NPI: 1700525342
Provider Name (Legal Business Name): AMANDA LUONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 S BASCOM AVE STE 104
CAMPBELL CA
95008-7317
US

IV. Provider business mailing address

3803 S BASCOM AVE STE 104
CAMPBELL CA
95008-7317
US

V. Phone/Fax

Practice location:
  • Phone: 888-345-4666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95186705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: