Provider Demographics
NPI:1679291983
Name:TEKLU, ELSA
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:TEKLU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 W EMILE ZOLA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-6049
Mailing Address - Country:US
Mailing Address - Phone:623-203-4561
Mailing Address - Fax:
Practice Address - Street 1:9126 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3116
Practice Address - Country:US
Practice Address - Phone:623-478-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP049618164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse