Provider Demographics
NPI:1164235990
Name:GONG, HALLIE MARIE
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:MARIE
Last Name:GONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HALLIE
Other - Middle Name:MARIE
Other - Last Name:GONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BIRTH DOULA
Mailing Address - Street 1:6576 ZION WAY
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92509-1926
Mailing Address - Country:US
Mailing Address - Phone:714-725-9140
Mailing Address - Fax:
Practice Address - Street 1:6576 ZION WAY
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-1926
Practice Address - Country:US
Practice Address - Phone:714-725-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374J00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula