Basic Information
| Provider Information | |||||||||
| NPI: | 1801832894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 CHESHIRE PKWY N | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554464103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885100766 | ||||||||
| FaxNumber: | 7632684017 | ||||||||
| Practice Location | |||||||||
| Address1: | 44407 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619427030 | ||||||||
| FaxNumber: | 6619420784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 06/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA7005 | CA | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | AU2439 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.