Healthcare Provider Details

I. General information

NPI: 1275460206
Provider Name (Legal Business Name): RAKEB TEMESELEW MAMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE
STATEN ISLAND NY
10310
US

IV. Provider business mailing address

YEKA B180 14
ADDIS ABABA ADDIS ABABA
10000
ET

V. Phone/Fax

Practice location:
  • Phone: 710-818-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: