Provider Demographics
NPI:1316540214
Name:KEBEDE, AYANTU
Entity Type:Individual
Prefix:MS
First Name:AYANTU
Middle Name:
Last Name:KEBEDE
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 1:433 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3629
Mailing Address - Country:US
Mailing Address - Phone:703-836-7668
Mailing Address - Fax:
Practice Address - Street 1:433 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3629
Practice Address - Country:US
Practice Address - Phone:703-836-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty