Healthcare Provider Details

I. General information

NPI: 1366107039
Provider Name (Legal Business Name): KRYSTLE JEANEE WONG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2021
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15464 GOLDENWEST ST.
WESTMINSTER CA
92683
US

IV. Provider business mailing address

15464 GOLDENWEST ST.
WESTMINSTER CA
92683
US

V. Phone/Fax

Practice location:
  • Phone: 714-891-9008
  • Fax: 714-897-7949
Mailing address:
  • Phone: 714-891-9008
  • Fax: 714-897-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: