Provider Demographics
NPI:1619644416
Name:HITZMAN-HUMPHREY, MONIQUE M
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:HITZMAN-HUMPHREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:M
Other - Last Name:HITZMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1301 11TH ST APT 10
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2057
Mailing Address - Country:US
Mailing Address - Phone:310-927-8632
Mailing Address - Fax:
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:818-686-3261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program