Provider Demographics
NPI:1982052684
Name:GEDAMU, LIA (NP)
Entity type:Individual
Prefix:
First Name:LIA
Middle Name:
Last Name:GEDAMU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARIKWA
Other - Middle Name:
Other - Last Name:GEDAMU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:206-860-5414
Mailing Address - Fax:
Practice Address - Street 1:16260 VENTURA BLVD
Practice Address - Street 2:LL-15
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2203
Practice Address - Country:US
Practice Address - Phone:818-905-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP70054264363L00000X
CA95003319363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner