Provider Demographics
NPI:1861872509
Name:FONG, MEELAIN
Entity type:Individual
Prefix:
First Name:MEELAIN
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 1:2630 SAN GABRIEL BLVD
Mailing Address - Street 2:#200
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-5204
Mailing Address - Country:US
Mailing Address - Phone:626-280-9968
Mailing Address - Fax:
Practice Address - Street 1:2630 SAN GABRIEL BLVD
Practice Address - Street 2:#200
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-5204
Practice Address - Country:US
Practice Address - Phone:626-280-9968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002048363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily