Provider Demographics
NPI:1790284776
Name:CHONG, LYDIA KUUIPO (ACNP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:KUUIPO
Last Name:CHONG
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19646 N 27TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4026
Mailing Address - Country:US
Mailing Address - Phone:602-663-9371
Mailing Address - Fax:602-456-6887
Practice Address - Street 1:19646 N 27TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4026
Practice Address - Country:US
Practice Address - Phone:602-663-9371
Practice Address - Fax:602-456-6887
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10674363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care