Healthcare Provider Details

I. General information

NPI: 1548540727
Provider Name (Legal Business Name): LILLY FUNG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 FAIRMONT DR
SAN LEANDRO CA
94578-1001
US

IV. Provider business mailing address

2620 MISSION ST
SAN FRANCISCO CA
94110-3102
US

V. Phone/Fax

Practice location:
  • Phone: 415-606-6403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number695604
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95000607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: