Provider Demographics
NPI:1275140410
Name:NGON, WINE
Entity Type:Individual
Prefix:
First Name:WINE
Middle Name:
Last Name:NGON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 LAKE LYNN DR APT 107
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3453
Mailing Address - Country:US
Mailing Address - Phone:910-729-3005
Mailing Address - Fax:
Practice Address - Street 1:4149 LAKE LYNN DR APT 107
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-3453
Practice Address - Country:US
Practice Address - Phone:910-729-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18856225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist