Provider Demographics
NPI:1780952630
Name:WONG, DIANNA H
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:H
Last Name:WONG
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 1:15850 EAST 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRA
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2024
Mailing Address - Country:US
Mailing Address - Phone:510-276-5743
Mailing Address - Fax:510-276-9027
Practice Address - Street 1:15850 E14 TH STREET
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2024
Practice Address - Country:US
Practice Address - Phone:510-276-5743
Practice Address - Fax:510-276-9027
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist