Provider Demographics
NPI:1437959822
Name:BONGOLAN, CHARLLIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:CHARLLIE
Middle Name:
Last Name:BONGOLAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17036 KIRK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6704
Mailing Address - Country:US
Mailing Address - Phone:626-347-2152
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily