Healthcare Provider Details

I. General information

NPI: 1891393088
Provider Name (Legal Business Name): KEDESSE YEMANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2020
Last Update Date: 10/11/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10628 PARK RD
CHARLOTTE NC
28210-8407
US

IV. Provider business mailing address

5211 HOLBERT CIR
CHARLOTTE NC
28269-0940
US

V. Phone/Fax

Practice location:
  • Phone: 704-807-6449
  • Fax:
Mailing address:
  • Phone: 704-807-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020000794
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: