Healthcare Provider Details

I. General information

NPI: 1104675412
Provider Name (Legal Business Name): BRENDA WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 MADISON AVE FL 1
MOUNT HOLLY NJ
08060-2099
US

IV. Provider business mailing address

1126 E PALMER ST UNIT 2
PHILADELPHIA PA
19125-4242
US

V. Phone/Fax

Practice location:
  • Phone: 856-430-9427
  • Fax:
Mailing address:
  • Phone: 646-323-7963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NR22515300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: