Healthcare Provider Details

I. General information

NPI: 1982052684
Provider Name (Legal Business Name): LIA GEDAMU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARIKWA GEDAMU

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD LL-15
ENCINO CA
91436-2203
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 818-905-1567
  • Fax:
Mailing address:
  • Phone: 206-860-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP70054264
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95003319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: