Provider Demographics
NPI:1174040885
Name:HENNESSEE, GLORIA GRACE (PCD(DONA))
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:GRACE
Last Name:HENNESSEE
Suffix:
Gender:F
Credentials:PCD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 WESTWOOD BLVD # 384
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2109
Mailing Address - Country:US
Mailing Address - Phone:310-502-6965
Mailing Address - Fax:
Practice Address - Street 1:11903 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1312
Practice Address - Country:US
Practice Address - Phone:310-502-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty