Provider Demographics
NPI:1891776357
Name:HWANGBO, HAILEY H (NP)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:H
Last Name:HWANGBO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 N 4TH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4309
Mailing Address - Country:US
Mailing Address - Phone:323-201-4130
Mailing Address - Fax:323-201-4134
Practice Address - Street 1:433 N 4TH ST STE 208
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4309
Practice Address - Country:US
Practice Address - Phone:323-201-4130
Practice Address - Fax:323-201-4134
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15839363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner