Healthcare Provider Details

I. General information

NPI: 1326700477
Provider Name (Legal Business Name): MICHAEL SEYOUM WENDIMU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 SAWTELLE BLVD APT # 206
LOS ANGELES CA
90066
US

IV. Provider business mailing address

3130 SAWTELLE BLVD APT # 206
LOS ANGELES CA
90066
US

V. Phone/Fax

Practice location:
  • Phone: 310-628-5498
  • Fax:
Mailing address:
  • Phone: 310-628-5498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95018710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: