Provider Demographics
NPI:1336611169
Name:HAILE, GHIRMAY (DNP, PMHNP - BC)
Entity type:Individual
Prefix:
First Name:GHIRMAY
Middle Name:
Last Name:HAILE
Suffix:
Gender:M
Credentials:DNP, PMHNP - BC
Other - Prefix:
Other - First Name:GHIRMAY
Other - Middle Name:HAILE
Other - Last Name:GHEBRESLASSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP, PMHNP - BC
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:535 S. MIRANDA ST.
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:575-647-2800
Practice Address - Fax:575-647-2898
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-80088163W00000X
NM55118363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32474385Medicaid