Provider Demographics
NPI:1821329525
Name:FONG, LYNN M (RD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:FONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9754 TAPESTRY DR
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-9634
Mailing Address - Country:US
Mailing Address - Phone:408-847-1722
Mailing Address - Fax:
Practice Address - Street 1:9754 TAPESTRY DR
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-9634
Practice Address - Country:US
Practice Address - Phone:408-847-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA874025133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered