Provider Demographics
NPI:1518923937
Name:FONG, MARCELLA (NP)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:
Other - Last Name:LEONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:2545 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2839
Practice Address - Country:US
Practice Address - Phone:209-957-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA244783163W00000X
CA1033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3300814Medicaid
CAZZZ22190YMedicare PIN
CARN3300814Medicaid