Provider Demographics
NPI:1770254393
Name:TEKLAI, MISGANA
Entity Type:Individual
Prefix:
First Name:MISGANA
Middle Name:
Last Name:TEKLAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2127 CLEMATIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-5218
Mailing Address - Country:US
Mailing Address - Phone:619-757-5363
Mailing Address - Fax:
Practice Address - Street 1:340 S LEMON AVE # 9892
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2706
Practice Address - Country:US
Practice Address - Phone:415-403-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403627363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health