Provider Demographics
NPI:1114364668
Name:TEWOLDE, MESSERET M (CNP)
Entity Type:Individual
Prefix:
First Name:MESSERET
Middle Name:M
Last Name:TEWOLDE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 E BROAD ST STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2979
Mailing Address - Country:US
Mailing Address - Phone:614-655-3345
Mailing Address - Fax:614-253-8539
Practice Address - Street 1:6400 E BROAD ST STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2979
Practice Address - Country:US
Practice Address - Phone:614-655-3345
Practice Address - Fax:614-317-4689
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14280-NP363LF0000X
OHAPRN.CNP.14280363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085847Medicaid