Healthcare Provider Details

I. General information

NPI: 1578710323
Provider Name (Legal Business Name): BISRAT G TESFAI NURSE LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2008
Last Update Date: 08/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 CITY VIEW PL
SAN JOSE CA
95127-4333
US

IV. Provider business mailing address

4672 MORNING BROOK LN
TRACY CA
95377-8715
US

V. Phone/Fax

Practice location:
  • Phone: 408-254-1040
  • Fax:
Mailing address:
  • Phone: 208-835-7696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 155621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: