Provider Demographics
NPI:1912104522
Name:FONG, JENNIFER SONG (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SONG
Last Name:FONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SONG
Other - Last Name:LECLERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:18 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2311
Mailing Address - Country:US
Mailing Address - Phone:914-288-8058
Mailing Address - Fax:
Practice Address - Street 1:3415 BAINBRIDGE AVE
Practice Address - Street 2:CHILDRENS HOSPITAL OF MONTEFIORE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-741-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY381662363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics