Provider Demographics
NPI:1508619164
Name:YADETA, ABISHALOM KITATA
Entity Type:Individual
Prefix:
First Name:ABISHALOM
Middle Name:KITATA
Last Name:YADETA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 CENTURY CITY E APT 11
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2775
Mailing Address - Country:US
Mailing Address - Phone:120-682-2152
Mailing Address - Fax:
Practice Address - Street 1:1801 CENTURY CITY E APT 11
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2775
Practice Address - Country:US
Practice Address - Phone:614-714-8549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH532862163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse