Provider Demographics
NPI:1205891314
Name:WONG, SHELLEY L (FNP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:L
Last Name:WONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR STE 200
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-427-4900
Practice Address - Fax:707-428-2715
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13957363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMW1160871OtherDEA
CAYYY48297YMedicare PIN