Healthcare Provider Details

I. General information

NPI: 1205189032
Provider Name (Legal Business Name): PATRICIA AIE-LAN WONG FNP-BC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CENTRE ST
ROSLINDALE MA
02131-1000
US

IV. Provider business mailing address

1200 CENTRE ST
ROSLINDALE MA
02131-1000
US

V. Phone/Fax

Practice location:
  • Phone: 617-363-8010
  • Fax: 617-363-8929
Mailing address:
  • Phone: 617-363-8010
  • Fax: 617-363-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN2264036
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: