Healthcare Provider Details

I. General information

NPI: 1255891438
Provider Name (Legal Business Name): MELAT FEKADE HAILE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 MARENGO ST
LOS ANGELES CA
90033-1352
US

IV. Provider business mailing address

6234 WOODMAN AVE APT 102
VAN NUYS CA
91401-2986
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-7728
  • Fax:
Mailing address:
  • Phone: 909-568-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95010805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: