Provider Demographics
NPI:1992804660
Name:HAKVONGSA, KEOVIENGKHONE MERINA (NP)
Entity type:Individual
Prefix:
First Name:KEOVIENGKHONE
Middle Name:MERINA
Last Name:HAKVONGSA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KEOVIENGKHONE
Other - Middle Name:MERINA
Other - Last Name:LATIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:45640 SCHOENHERR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6033
Mailing Address - Country:US
Mailing Address - Phone:586-247-4300
Mailing Address - Fax:586-532-6496
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:SUITE 150
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:586-247-4300
Practice Address - Fax:586-532-6496
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704212195363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774815800Medicaid