Healthcare Provider Details

I. General information

NPI: 1881946663
Provider Name (Legal Business Name): YERUKNESH ADMASSU ENDALAMAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 GREENCASTLE RD
LAUREL MD
20707-3142
US

IV. Provider business mailing address

4710 GREENCASTLE RD
LAUREL MD
20707-3142
US

V. Phone/Fax

Practice location:
  • Phone: 571-405-8992
  • Fax:
Mailing address:
  • Phone: 571-405-8992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1018824
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: