Provider Demographics
NPI:1528542776
Name:TESFAYE, NISHAN A (RCP)
Entity Type:Individual
Prefix:
First Name:NISHAN
Middle Name:A
Last Name:TESFAYE
Suffix:
Gender:F
Credentials:RCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-1608
Mailing Address - Country:US
Mailing Address - Phone:323-735-5765
Mailing Address - Fax:
Practice Address - Street 1:4867 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5969
Practice Address - Country:US
Practice Address - Phone:323-783-7920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-23
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23918226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist