Healthcare Provider Details

I. General information

NPI: 1023429859
Provider Name (Legal Business Name): DIANE ANGELA FONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 EL CAMINO REAL STE 110
LOS ALTOS CA
94065
US

IV. Provider business mailing address

16 PORTOFINO CIR
REDWOOD CITY CA
94065-1341
US

V. Phone/Fax

Practice location:
  • Phone: 650-964-6700
  • Fax: 650-964-3495
Mailing address:
  • Phone: 917-613-6440
  • Fax: 650-964-3495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: