Provider Demographics
NPI:1780881482
Name:TANGONAN, AILEEN C (MSN NP)
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:C
Last Name:TANGONAN
Suffix:
Gender:F
Credentials:MSN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 MONTEREY BLVD
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-5141
Mailing Address - Country:US
Mailing Address - Phone:310-386-5751
Mailing Address - Fax:
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-633-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA583576163W00000X
CA15854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15854OtherNURSE PRACTIONER LICENSE