Provider Demographics
NPI:1144775966
Name:HAILU, HIENOK
Entity Type:Individual
Prefix:
First Name:HIENOK
Middle Name:
Last Name:HAILU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 CASA GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4223
Mailing Address - Country:US
Mailing Address - Phone:314-255-8395
Mailing Address - Fax:
Practice Address - Street 1:11725 CASA GRANDE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4223
Practice Address - Country:US
Practice Address - Phone:314-255-8395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016015067363LA2200X
MO20160156067363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health