Provider Demographics
NPI:1255859542
Name:FAN, YI FEN (LAC)
Entity Type:Individual
Prefix:
First Name:YI FEN
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 TREELANE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4948
Mailing Address - Country:US
Mailing Address - Phone:626-863-8288
Mailing Address - Fax:
Practice Address - Street 1:8835 LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-1821
Practice Address - Country:US
Practice Address - Phone:626-285-7588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF2577114OtherDRIVER LISCENCE