Healthcare Provider Details

I. General information

NPI: 1891776357
Provider Name (Legal Business Name): HAILEY H HWANGBO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 N 4TH ST STE 208
MONTEBELLO CA
90640-4309
US

IV. Provider business mailing address

433 N 4TH ST STE 208
MONTEBELLO CA
90640-4309
US

V. Phone/Fax

Practice location:
  • Phone: 323-201-4130
  • Fax: 323-201-4134
Mailing address:
  • Phone: 323-201-4130
  • Fax: 323-201-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP15839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: