Healthcare Provider Details

I. General information

NPI: 1902535933
Provider Name (Legal Business Name): HEYABE KIDANE STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

6215 61ST PL
RIVERDALE MD
20737-2130
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-0000
  • Fax:
Mailing address:
  • Phone: 301-412-7823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberNP1032518
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: