Provider Demographics
NPI:1790142008
Name:MAMO, ETENESH
Entity Type:Individual
Prefix:
First Name:ETENESH
Middle Name:
Last Name:MAMO
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 1:4207 ARKANSAS AVE NW
Mailing Address - Street 2:APT 2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5542
Mailing Address - Country:US
Mailing Address - Phone:703-380-1595
Mailing Address - Fax:
Practice Address - Street 1:4207 ARKANSAS AVE NW
Practice Address - Street 2:APT 2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5542
Practice Address - Country:US
Practice Address - Phone:703-380-1595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11723374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide