Basic Information
| Provider Information | |||||||||
| NPI: | 1992804660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAKVONGSA | ||||||||
| FirstName: | KEOVIENGKHONE | ||||||||
| MiddleName: | MERINA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LATIMER | ||||||||
| OtherFirstName: | KEOVIENGKHONE | ||||||||
| OtherMiddleName: | MERINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 45640 SCHOENHERR RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483156033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862474300 | ||||||||
| FaxNumber: | 5865326496 | ||||||||
| Practice Location | |||||||||
| Address1: | 22201 MOROSS RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482362169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862474300 | ||||||||
| FaxNumber: | 5865326496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704212195 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.