Healthcare Provider Details

I. General information

NPI: 1043190556
Provider Name (Legal Business Name): AYALENSH TESERA GEBREHIWOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 TOWER CT APT 803
ALEXANDRIA VA
22304-3223
US

IV. Provider business mailing address

6060 TOWER CT APT 803
ALEXANDRIA VA
22304-3223
US

V. Phone/Fax

Practice location:
  • Phone: 703-801-0009
  • Fax:
Mailing address:
  • Phone: 703-801-0009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: