Provider Demographics
NPI:1235626854
Name:MOHAMMED, KHERIYA BERHAN (RN)
Entity Type:Individual
Prefix:
First Name:KHERIYA
Middle Name:BERHAN
Last Name:MOHAMMED
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-542-4060
Mailing Address - Fax:
Practice Address - Street 1:655 PARK CENTER DR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-6957
Practice Address - Country:US
Practice Address - Phone:619-596-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN259770164X00000X
CA95173019163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty