Healthcare Provider Details

I. General information

NPI: 1093453359
Provider Name (Legal Business Name): MOLLY WINTER HANNA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 W OLYMPIC BLVD
LOS ANGELES CA
90064-5001
US

IV. Provider business mailing address

11835 W OLYMPIC BLVD STE 1265E
LOS ANGELES CA
90064-5814
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-4843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPENDING
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4716839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: