Healthcare Provider Details

I. General information

NPI: 1497626436
Provider Name (Legal Business Name): YENEALEM TESFAYE TASSEW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20834 4TH PL S
DES MOINES WA
98198-3613
US

IV. Provider business mailing address

20834 4TH PL S
DES MOINES WA
98198-3613
US

V. Phone/Fax

Practice location:
  • Phone: 206-488-9680
  • Fax: 206-480-0721
Mailing address:
  • Phone: 206-488-9680
  • Fax: 206-480-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number757808
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: