Healthcare Provider Details

I. General information

NPI: 1548918972
Provider Name (Legal Business Name): JUSTINA WONG CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM ST
SAN DIEGO CA
92101-2692
US

IV. Provider business mailing address

5550 BALBOA ARMS DR APT 18
SAN DIEGO CA
92117-5048
US

V. Phone/Fax

Practice location:
  • Phone: 619-677-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95020317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95020317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: