Healthcare Provider Details

I. General information

NPI: 1366351876
Provider Name (Legal Business Name): JIHYUN WONG
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16685 SIERRA LAKES PKWY # 100
FONTANA CA
92336-1255
US

IV. Provider business mailing address

16685 SIERRA LAKES PKWY # 100
FONTANA CA
92336-1255
US

V. Phone/Fax

Practice location:
  • Phone: 909-347-0009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95039964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: