Provider Demographics
NPI:1457096828
Name:FONG, KEMOY
Entity Type:Individual
Prefix:
First Name:KEMOY
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 W LAKEWOOD LN APT 3B
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8230
Mailing Address - Country:US
Mailing Address - Phone:407-616-3976
Mailing Address - Fax:
Practice Address - Street 1:2620 W LAKEWOOD LN APT 3B
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8230
Practice Address - Country:US
Practice Address - Phone:407-616-3976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11742-33363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care