Healthcare Provider Details

I. General information

NPI: 1144865999
Provider Name (Legal Business Name): ELENY TADESE GEBRE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 SUDLEY RD
MANASSAS VA
20110-8321
US

IV. Provider business mailing address

9437 HUCKS BRIDGE CIR
LORTON VA
22079-5001
US

V. Phone/Fax

Practice location:
  • Phone: 703-393-8883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178471
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: