=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891776357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAILEY H HWANGBO NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 N 4TH ST STE 208
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-201-4130
-----------------------------------------------------
Fax | 323-201-4134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 433 N 4TH ST STE 208
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-201-4130
-----------------------------------------------------
Fax | 323-201-4134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | NP15839
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------