Healthcare Provider Details

I. General information

NPI: 1891351821
Provider Name (Legal Business Name): MESERET BEKELE FANTA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 7TH AVENUE
SANTA CRUZ CA
95062-2717
US

IV. Provider business mailing address

1280 7TH AVENUE
SANTA CRUZ CA
95062-2717
US

V. Phone/Fax

Practice location:
  • Phone: 831-227-7996
  • Fax:
Mailing address:
  • Phone: 831-227-7996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number507046
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number507046
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number507046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: