MEDICARE: WOSENE TIKUYE G EYESSUS

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1619651262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WOSENE TIKUYE G EYESSUS

Provider Business Mailing Address
First Line	:	780 FAIRVIEW AVE APT 605
Second Line	:
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912-5951
Country	:	US
Telephone Number	:	301-825-6312
Fax Number	:

Provider Business Practice Location Address
First Line	:	780 FAIRVIEW AVE APT 605
Second Line	:
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912-5951
Country	:	US
Telephone Number	:	301-825-6312
Fax Number	:

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

Provider Enumeration Date	:	06/14/2023
Last Update Date	:	06/14/2023

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