Provider Demographics
NPI:1710518808
Name:DATE-CHONG, LAUREN NICOLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:DATE-CHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 RAVENHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-2725
Mailing Address - Country:US
Mailing Address - Phone:925-915-9918
Mailing Address - Fax:
Practice Address - Street 1:174 RAVENHILL RD
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-2725
Practice Address - Country:US
Practice Address - Phone:925-915-9918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013441363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics