Healthcare Provider Details

I. General information

NPI: 1811870462
Provider Name (Legal Business Name): GEBREHIWOT HAILU YIBALIH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7136 HASKELL AVE STE 205
VAN NUYS CA
91406-4112
US

IV. Provider business mailing address

1902 WELLINGTON RD APT 1
LOS ANGELES CA
90016-1880
US

V. Phone/Fax

Practice location:
  • Phone: 818-908-4086
  • Fax:
Mailing address:
  • Phone: 323-470-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07251146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: