Provider Demographics
NPI:1114475571
Name:WONG, I LAM (RD)
Entity Type:Individual
Prefix:
First Name:I LAM
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CRYSTAL SPRINGS RD
Mailing Address - Street 2:APT 2123
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 CRYSTAL SPRINGS RD
Practice Address - Street 2:APT 2123
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-4638
Practice Address - Country:US
Practice Address - Phone:408-705-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1103791133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered