Healthcare Provider Details

I. General information

NPI: 1194497628
Provider Name (Legal Business Name): TSIGEMARIAM YOHANNES GEBREMARIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11218 W BERKELEY RD
AVONDALE AZ
85392-5083
US

IV. Provider business mailing address

11218 W BERKELEY RD
AVONDALE AZ
85392-5083
US

V. Phone/Fax

Practice location:
  • Phone: 617-785-6933
  • Fax:
Mailing address:
  • Phone: 617-785-6693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN186932
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: