Provider Demographics
NPI:1982028973
Name:FONG, ILIA (AUD)
Entity Type:Individual
Prefix:
First Name:ILIA
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 NE CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5434
Mailing Address - Country:US
Mailing Address - Phone:503-346-0640
Mailing Address - Fax:503-346-0645
Practice Address - Street 1:6355 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5434
Practice Address - Country:US
Practice Address - Phone:503-346-0640
Practice Address - Fax:503-346-0645
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR030788231H00000X
CAAU2951231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist