Basic Information
| Provider Information | |||||||||
| NPI: | 1558310755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELAKU | ||||||||
| FirstName: | HABTAMUA | ||||||||
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| Credential: | DNP, MSN, FNP, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 546 N JEFFERSON LN | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992017104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096240111 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN00114991 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP30004850 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP30004850 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 147661 | 01 | WA | L & I | OTHER | 9626581 | 05 | WA | MEDICAID |