Provider Demographics
NPI:1376827436
Name:FONG, ALICE L (ND, LMT)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:L
Last Name:FONG
Suffix:
Gender:F
Credentials:ND, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 J ST STE B
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3840
Mailing Address - Country:US
Mailing Address - Phone:443-595-6688
Mailing Address - Fax:
Practice Address - Street 1:5120 J ST STE B
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3840
Practice Address - Country:US
Practice Address - Phone:443-595-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDJ0000004175F00000X
CA1043175F00000X
DCNP-0069175F00000X
WANT60309899175F00000X
CA77164225700000X
DCMT2071225700000X
WAMA60018737225700000X
MDM05533225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist