Healthcare Provider Details

I. General information

NPI: 1811807852
Provider Name (Legal Business Name): SELOME FIRISSA DEREJE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7071 UPPER 164TH ST W
ROSEMOUNT MN
55068-5255
US

IV. Provider business mailing address

7071 UPPER 164TH ST W
ROSEMOUNT MN
55068-5255
US

V. Phone/Fax

Practice location:
  • Phone: 651-329-2807
  • Fax:
Mailing address:
  • Phone: 651-329-2807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1122635
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: