MEDICARE: MS. ENATALEM GETACHEW EJERSSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WM1400X	Nurse Massage Therapist (NMT)	0019017981	VA
2	225700000X	Massage Therapist	R02544	MD

General Provider Information

NPI Number	:	1407422033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ENATALEM GETACHEW EJERSSA

Provider Business Mailing Address
First Line	:	1215 PALMER RD APT 1
Second Line	:
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-7143
Country	:	US
Telephone Number	:	510-692-2053
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 PALMER RD APT 1
Second Line	:
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-7143
Country	:	US
Telephone Number	:	510-692-2053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	06/03/2021

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