Provider Demographics
NPI:1043873516
Name:HAILE, GIRMACHEW
Entity type:Individual
Prefix:
First Name:GIRMACHEW
Middle Name:
Last Name:HAILE
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 1:3512 COOKE LN
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-1801
Mailing Address - Country:US
Mailing Address - Phone:773-681-1505
Mailing Address - Fax:
Practice Address - Street 1:3512 COOKE LN
Practice Address - Street 2:
Practice Address - City:MELISSA
Practice Address - State:TX
Practice Address - Zip Code:75454-1801
Practice Address - Country:US
Practice Address - Phone:773-681-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1025793363LP2300X
TX844247163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care