Provider Demographics
NPI:1073397642
Name:BEDASSO, BETHELEM WONDIMU
Entity Type:Individual
Prefix:
First Name:BETHELEM
Middle Name:WONDIMU
Last Name:BEDASSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 QUIVIRA RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-3526
Mailing Address - Country:US
Mailing Address - Phone:913-706-2508
Mailing Address - Fax:
Practice Address - Street 1:7450 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-3526
Practice Address - Country:US
Practice Address - Phone:913-706-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-82444-092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health