Healthcare Provider Details

I. General information

NPI: 1770192924
Provider Name (Legal Business Name): PENNIE KHONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 08/16/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 SPANGLER LN STE 400
COPPEROPOLIS CA
95228-9424
US

IV. Provider business mailing address

3505 SPANGLER LN STE 400
COPPEROPOLIS CA
95228-9424
US

V. Phone/Fax

Practice location:
  • Phone: 209-785-7000
  • Fax:
Mailing address:
  • Phone: 209-785-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61090460
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: