Provider Demographics
NPI:1407422033
Name:EJERSSA, ENATALEM GETACHEW
Entity Type:Individual
Prefix:MS
First Name:ENATALEM
Middle Name:GETACHEW
Last Name:EJERSSA
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 1:1215 PALMER RD APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-7143
Mailing Address - Country:US
Mailing Address - Phone:510-692-2053
Mailing Address - Fax:
Practice Address - Street 1:1215 PALMER RD APT 1
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-7143
Practice Address - Country:US
Practice Address - Phone:510-692-2053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019017981163WM1400X
MDR02544225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)