Healthcare Provider Details

I. General information

NPI: 1790204600
Provider Name (Legal Business Name): TIRSIT GEBRESENBET NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 W COOLIDGE ST
PHOENIX AZ
85013
US

IV. Provider business mailing address

9843 W KEYSER DR
PEORIA AZ
85383-2913
US

V. Phone/Fax

Practice location:
  • Phone: 602-248-0550
  • Fax: 602-248-0557
Mailing address:
  • Phone: 602-373-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP10518
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP10518
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: