Provider Demographics
NPI:1336482280
Name:LULU, DEREJE G (NAC,)
Entity Type:Individual
Prefix:
First Name:DEREJE
Middle Name:G
Last Name:LULU
Suffix:
Gender:M
Credentials:NAC,
Other - Prefix:
Other - First Name:UTHIOPIA
Other - Middle Name:IN HOME CARE
Other - Last Name:IN HOME CARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HOME CARE
Mailing Address - Street 1:14100 LINDEN AVE N
Mailing Address - Street 2:# 418
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-7154
Mailing Address - Country:US
Mailing Address - Phone:206-549-9648
Mailing Address - Fax:206-494-7848
Practice Address - Street 1:14100 LINDEN AVE N
Practice Address - Street 2:# 418
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-7154
Practice Address - Country:US
Practice Address - Phone:206-414-4710
Practice Address - Fax:206-494-7848
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 385H00000X
WAIHS.FS.60405684251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAIHS.FS.60405684OtherWASHINGTON STATE HOME CARE AGENCE LICENSES PERMITSAND CERTIFICATES