Healthcare Provider Details

I. General information

NPI: 1902792260
Provider Name (Legal Business Name): KIANA JULIETTE YEGANEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2025
Last Update Date: 06/14/2025
Certification Date: 06/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 AVE ASHFORD
SAN JUAN PR
00907-1511
US

IV. Provider business mailing address

5611 ROOSEVELT ST
BETHESDA MD
20817-6739
US

V. Phone/Fax

Practice location:
  • Phone: 301-541-9753
  • Fax:
Mailing address:
  • Phone: 301-541-9753
  • 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: