Provider Demographics
NPI:1497379663
Name:TEKLAY, HAGOS KIFLAY
Entity Type:Individual
Prefix:
First Name:HAGOS
Middle Name:KIFLAY
Last Name:TEKLAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6991 BALBOA AVE RM 70
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3447
Mailing Address - Country:US
Mailing Address - Phone:858-496-8232
Mailing Address - Fax:858-496-8234
Practice Address - Street 1:6991 BALBOA AVE RM 70
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3447
Practice Address - Country:US
Practice Address - Phone:858-496-8232
Practice Address - Fax:858-496-8234
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95152885163WP0809X
CAPHN559278163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHN559278OtherTHE STATE OF CALIFORNIA