Provider Demographics
NPI:1033308366
Name:WONG, SALLY S (MS, RD, CDN)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:S
Last Name:WONG
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15014 JEWEL AVE
Mailing Address - Street 2:APT. 53B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1434
Mailing Address - Country:US
Mailing Address - Phone:917-696-4665
Mailing Address - Fax:
Practice Address - Street 1:254 CANAL ST
Practice Address - Street 2:SUITE 3002
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3501
Practice Address - Country:US
Practice Address - Phone:212-431-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005757-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ28647Medicare UPIN
NY9311E1Medicare PIN