Healthcare Provider Details

I. General information

NPI: 1912175787
Provider Name (Legal Business Name): SELAMAWIT TEKIE GEBRESLASSIE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SELAMAWIT TEKIE GEBREZGHI FNP

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

PO BOX 11643
SANTA ROSA CA
95406-1643
US

V. Phone/Fax

Practice location:
  • Phone: 707-393-4000
  • Fax:
Mailing address:
  • Phone: 916-842-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: