Provider Demographics
NPI:1942605126
Name:MEKONNEN, ASSEFA EJIGU (PMHNP)
Entity Type:Individual
Prefix:
First Name:ASSEFA
Middle Name:EJIGU
Last Name:MEKONNEN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4570
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-9607
Mailing Address - Country:US
Mailing Address - Phone:424-400-7748
Mailing Address - Fax:424-400-7749
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-7329
Practice Address - Country:US
Practice Address - Phone:213-989-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001041363LF0000X, 363LP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health