Provider Demographics
NPI:1013388842
Name:WONG, GENEVIEVE (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MELA LN
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5084
Mailing Address - Country:US
Mailing Address - Phone:310-924-9195
Mailing Address - Fax:
Practice Address - Street 1:1316 3RD STREET PROMENADE
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1328
Practice Address - Country:US
Practice Address - Phone:800-576-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95062564163W00000X
CA95003281363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95062564OtherCA REGISTERED NURSE LICENSE NUMBER
CA95003281OtherCA NURSE PRACTITIONER LICENSE NUMBER