Healthcare Provider Details

I. General information

NPI: 1003525585
Provider Name (Legal Business Name): LESLIE FUNG CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2022
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 S GRAND AVE STE 220&250
LOS ANGELES CA
90015-3070
US

IV. Provider business mailing address

1830 41ST AVE
SAN FRANCISCO CA
94122-4004
US

V. Phone/Fax

Practice location:
  • Phone: 415-963-2968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236344
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number802414
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: