Provider Demographics
NPI:1477258515
Name:MENGISTU, ASNAKECH
Entity Type:Individual
Prefix:
First Name:ASNAKECH
Middle Name:
Last Name:MENGISTU
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 1:1950 N WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-3568
Mailing Address - Country:US
Mailing Address - Phone:517-515-3060
Mailing Address - Fax:
Practice Address - Street 1:1950 N WAVERLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-3568
Practice Address - Country:US
Practice Address - Phone:517-515-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS3304131523747A0650X, 374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health Aide