Provider Demographics
NPI:1528218211
Name:AVECILLA, HANNIBAL GERHSON (MSN, RN, CNOR, FNP)
Entity Type:Individual
Prefix:MR
First Name:HANNIBAL
Middle Name:GERHSON
Last Name:AVECILLA
Suffix:
Gender:M
Credentials:MSN, RN, CNOR, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E CALIFORNIA AVE
Mailing Address - Street 2:UNIT H
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-3852
Mailing Address - Country:US
Mailing Address - Phone:818-547-9564
Mailing Address - Fax:
Practice Address - Street 1:1200 E CALIFORNIA AVE
Practice Address - Street 2:UNIT H
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3852
Practice Address - Country:US
Practice Address - Phone:818-547-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15503363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily