Provider Demographics
NPI:1114102209
Name:FONG, AMY ELIZABETH (MPT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:FONG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:GIDDENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16950 VIA TAZON
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1607
Mailing Address - Country:US
Mailing Address - Phone:858-521-2265
Mailing Address - Fax:
Practice Address - Street 1:16950 VIA TAZON
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1607
Practice Address - Country:US
Practice Address - Phone:858-521-2265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA256912251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic