Healthcare Provider Details

I. General information

NPI: 1407765464
Provider Name (Legal Business Name): LEMLEM TEWOLDE GHEBREMARIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST
SAN FRANCISCO CA
94121-1563
US

IV. Provider business mailing address

4765 ORVILLE AVE
SANTA ROSA CA
95407-6663
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-4810
  • Fax:
Mailing address:
  • Phone: 707-623-5694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number266358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: