Healthcare Provider Details

I. General information

NPI: 1992376636
Provider Name (Legal Business Name): CRYSTAL HUONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2021
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 S DIAMOND BAR BLVD STE 100
DIAMOND BAR CA
91765-3557
US

IV. Provider business mailing address

1634 ALEGRO SQ APT J
SAN GABRIEL CA
91776-3946
US

V. Phone/Fax

Practice location:
  • Phone: 626-965-1988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: