Healthcare Provider Details

I. General information

NPI: 1275861353
Provider Name (Legal Business Name): WONDAYE TAMENE DERESSA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

10040 FALL RAIN DR
LAUREL MD
20723-5771
US

V. Phone/Fax

Practice location:
  • Phone: 301-400-1133
  • Fax:
Mailing address:
  • Phone: 240-355-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR146322
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: