Healthcare Provider Details

I. General information

NPI: 1417876178
Provider Name (Legal Business Name): MAKEDA TAYE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 JESSIE AVE
SACRAMENTO CA
95838-2609
US

IV. Provider business mailing address

10483 VIVA CT
ELK GROVE CA
95757-5268
US

V. Phone/Fax

Practice location:
  • Phone: 916-668-0683
  • Fax: 888-719-2432
Mailing address:
  • Phone: 916-752-7974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: