=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417201815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOKONNEN B WOBE HHA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2012
-----------------------------------------------------
Last Update Date | 11/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4422 7TH ST NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20017-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-527-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3925 GEORGIA AVE NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20011-5860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-527-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | CAPTH1153
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------