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General NPI Number Information
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NPI Number | 1184994105
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Entity Type | Individual
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Provider Name | BERHANU EJIGU KEDEDA NP-C
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Gender | Male
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Dates
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Enumeration Date | 01/06/2012
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Last Update Date | 10/09/2025
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Provider Practice Location Address
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Address Line | 5576 PRINCETON RUN TRL
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City | TUCKER
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State | GA
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Zip | 30084-8463
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Country | US
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Telephone | 678-793-8808
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Fax |
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Provider Business Mailing Address
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Address Line | 5576 PRINCETON RUN TRL
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City | TUCKER
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State | GA
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Zip | 30084-8463
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Country | US
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Telephone | 678-793-8808
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WH0200X
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Taxonomy Name | Home Health Registered Nurse
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License Number | 202205124RN
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN152429
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License Number State | GA
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