Provider Demographics
NPI:1346734001
Name:GONG, STEPHANIE X (LAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:X
Last Name:GONG
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 1:6276 CAMINO DEL LAGO
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-8647
Mailing Address - Country:US
Mailing Address - Phone:925-895-8395
Mailing Address - Fax:
Practice Address - Street 1:4080 EAST AVE
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4941
Practice Address - Country:US
Practice Address - Phone:925-606-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2018-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18004171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist