Basic Information
| Provider Information | |||||||||
| NPI: | 1942605126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEKONNEN | ||||||||
| FirstName: | ASSEFA | ||||||||
| MiddleName: | EJIGU | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4570 | ||||||||
| Address2: | |||||||||
| City: | PALOS VERDES PENINSULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902749607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4244007748 | ||||||||
| FaxNumber: | 4244007749 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 W TEMPLE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900267329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95001041 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WP0808X | 95001041 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.