Healthcare Provider Details

I. General information

NPI: 1679488928
Provider Name (Legal Business Name): BELAYNESH WOLDEMARIAM
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3092 MAPLE LEAF CT
LITTLE CANADA MN
55109-5299
US

IV. Provider business mailing address

3092 MAPLE LEAF CT
LITTLE CANADA MN
55109-5299
US

V. Phone/Fax

Practice location:
  • Phone: 651-675-7151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1065470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: