Healthcare Provider Details

I. General information

NPI: 1659902120
Provider Name (Legal Business Name): ALEGNTAYE YIRDAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 S BUCKNER BLVD
DALLAS TX
75227-6904
US

IV. Provider business mailing address

7700 CODY LN APT 3044
SACHSE TX
75048-6687
US

V. Phone/Fax

Practice location:
  • Phone: 214-388-1100
  • Fax:
Mailing address:
  • Phone: 214-205-1319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP142463
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP142463
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP142463
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: