Provider Demographics
NPI:1700767944
Name:HAKANSON, LEITHA
Entity type:Individual
Prefix:
First Name:LEITHA
Middle Name:
Last Name:HAKANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17343 BURMA ST
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1334
Mailing Address - Country:US
Mailing Address - Phone:818-486-9075
Mailing Address - Fax:
Practice Address - Street 1:625 W COLLEGE ST STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1650
Practice Address - Country:US
Practice Address - Phone:213-265-7433
Practice Address - Fax:213-265-7531
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty