Healthcare Provider Details

I. General information

NPI: 1578024519
Provider Name (Legal Business Name): STACEY GUO CHONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8821 NE 5TH ST
VANCOUVER WA
98664
US

IV. Provider business mailing address

505 NE 87TH AVE STE 460
VANCOUVER WA
98664-1965
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2340
  • Fax: 360-514-2345
Mailing address:
  • Phone: 360-514-2340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD61483707
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA176604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: