Provider Demographics
NPI:1003205279
Name:FONGE, THERESIA
Entity Type:Individual
Prefix:MS
First Name:THERESIA
Middle Name:
Last Name:FONGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 HICKORY CREEK DR
Mailing Address - Street 2:APT 8
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60484-2740
Mailing Address - Country:US
Mailing Address - Phone:630-936-9862
Mailing Address - Fax:
Practice Address - Street 1:4790 HICKORY CREEK DR
Practice Address - Street 2:APT 8
Practice Address - City:UNIVERSITY PARK
Practice Address - State:IL
Practice Address - Zip Code:60484-2740
Practice Address - Country:US
Practice Address - Phone:630-936-9862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)