Healthcare Provider Details

I. General information

NPI: 1700231123
Provider Name (Legal Business Name): MS. MONICA WING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDREN'S WAY
SAN DIEGO CA
92123
US

IV. Provider business mailing address

3020 CHILDREN'S WAY
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-1700
  • Fax:
Mailing address:
  • Phone: 858-576-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number86000843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: