Provider Demographics
NPI:1043873557
Name:FOX, LEA SHANGRAW (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:SHANGRAW
Last Name:FOX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3254 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3885
Practice Address - Fax:510-597-7148
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950115132080P0207X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology