MEDICARE: LEMLEM ERKETA EJO NURSE PRACTITIONER

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	363LP2300X	Primary Care Nurse Practitioner	NP1034115	DC
2	363LF0000X	Family Nurse Practitioner	NP1034115	DC

General Provider Information

NPI Number	:	1578326104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEMLEM ERKETA EJO NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	200 MACDILL BLVD
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20340-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 MACDILL BLVD
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20340-0001
Country	:	US
Telephone Number	:	703-275-5049
Fax Number	:

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

Provider Enumeration Date	:	02/05/2024
Last Update Date	:	02/05/2024

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