Healthcare Provider Details

I. General information

NPI: 1003736109
Provider Name (Legal Business Name): TAGESSE KEMISO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 PICADILLY CT
AURORA CO
80019-3626
US

IV. Provider business mailing address

4444 PICADILLY CT
AURORA CO
80019-3626
US

V. Phone/Fax

Practice location:
  • Phone: 720-592-9573
  • Fax:
Mailing address:
  • Phone: 720-592-9573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SR0400X
TaxonomyRehabilitation Clinical Nurse Specialist
License Number170805113
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: