Provider Demographics
NPI:1023429859
Name:FONG, DIANE ANGELA
Entity type:Individual
Prefix:
First Name:DIANE ANGELA
Middle Name:
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 1:16 PORTOFINO CIR
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94065-1341
Mailing Address - Country:US
Mailing Address - Phone:917-613-6440
Mailing Address - Fax:650-964-3495
Practice Address - Street 1:5050 EL CAMINO REAL
Practice Address - Street 2:STE 110
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94065
Practice Address - Country:US
Practice Address - Phone:650-964-6700
Practice Address - Fax:650-964-3495
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND656175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath