Provider Demographics
NPI:1366024572
Name:KEBEBEW, MINTWAB T
Entity Type:Individual
Prefix:
First Name:MINTWAB
Middle Name:T
Last Name:KEBEBEW
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 1:1522 DILSTON RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-2207
Mailing Address - Country:US
Mailing Address - Phone:240-428-5785
Mailing Address - Fax:
Practice Address - Street 1:7826 EASTERN AVE NW STE LL16
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1328
Practice Address - Country:US
Practice Address - Phone:202-723-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00154615374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide