Healthcare Provider Details

I. General information

NPI: 1942605126
Provider Name (Legal Business Name): ASSEFA EJIGU MEKONNEN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 W TEMPLE ST
LOS ANGELES CA
90026-7329
US

IV. Provider business mailing address

PO BOX 4570
PALOS VERDES PENINSULA CA
90274-9607
US

V. Phone/Fax

Practice location:
  • Phone: 213-989-6100
  • Fax:
Mailing address:
  • Phone: 424-400-7748
  • Fax: 424-400-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95001041
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95001041
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95001041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: