Provider Demographics
NPI:1801832894
Name:FONG, STACEY T
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:T
Last Name:FONG
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 1:5000 CHESHIRE PKWY N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4103
Mailing Address - Country:US
Mailing Address - Phone:888-510-0766
Mailing Address - Fax:763-268-4017
Practice Address - Street 1:44407 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3345
Practice Address - Country:US
Practice Address - Phone:661-942-7030
Practice Address - Fax:661-942-0784
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7005237700000X
CAAU2439237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist