Healthcare Provider Details

I. General information

NPI: 1548760069
Provider Name (Legal Business Name): KONJIT A GEBREYOHANNES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14058 ROLLING HILLS LN
DALLAS TX
75240-3808
US

IV. Provider business mailing address

333 MEADOWHILL DR
GARLAND TX
75043-3023
US

V. Phone/Fax

Practice location:
  • Phone: 214-796-9729
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number310206
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: