Provider Demographics
NPI:1467116590
Name:DEREBA, YALEMEFREA
Entity Type:Individual
Prefix:
First Name:YALEMEFREA
Middle Name:
Last Name:DEREBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:YALEMEFREA
Other - Middle Name:
Other - Last Name:DEREBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6270 LINCOLNIA RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1530
Mailing Address - Country:US
Mailing Address - Phone:571-290-9705
Mailing Address - Fax:
Practice Address - Street 1:6270 LINCOLNIA RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-1530
Practice Address - Country:US
Practice Address - Phone:571-290-9705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAB60015184343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)