Provider Demographics
NPI:1326821208
Name:WOYESSA, DEBISA KENATE SR
Entity Type:Individual
Prefix:
First Name:DEBISA
Middle Name:KENATE
Last Name:WOYESSA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14375 ANNAPOLIS LN N
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:55327-4428
Mailing Address - Country:US
Mailing Address - Phone:612-670-4721
Mailing Address - Fax:
Practice Address - Street 1:122 W FRANKLIN AVE STE 510
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2454
Practice Address - Country:US
Practice Address - Phone:763-222-6575
Practice Address - Fax:612-320-3257
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty