Provider Demographics
NPI:1407572100
Name:WONGSO, LINA MARY (LPN)
Entity Type:Individual
Prefix:
First Name:LINA
Middle Name:MARY
Last Name:WONGSO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13915 83RD AVE APT 419
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1508
Mailing Address - Country:US
Mailing Address - Phone:631-507-8298
Mailing Address - Fax:
Practice Address - Street 1:3711 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-1725
Practice Address - Country:US
Practice Address - Phone:718-606-3863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336222-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse