Healthcare Provider Details

I. General information

NPI: 1184994105
Provider Name (Legal Business Name): BERHANU EJIGU KEDEDA NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BERHANU KEDIDA EJIGU NP-C

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5576 PRINCETON RUN TRL
TUCKER GA
30084-8463
US

IV. Provider business mailing address

5576 PRINCETON RUN TRL
TUCKER GA
30084-8463
US

V. Phone/Fax

Practice location:
  • Phone: 678-793-8808
  • Fax:
Mailing address:
  • Phone: 678-793-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number202205124RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN152429
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: