Healthcare Provider Details

I. General information

NPI: 1538828470
Provider Name (Legal Business Name): FIREW WORKNEH YIMER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

13611 CANYON GALE LN
PEARLAND TX
77584-4141
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax:
Mailing address:
  • Phone: 713-298-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1018700
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number70829
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: