Provider Demographics
NPI:1851191639
Name:WELDEKRISTOS, RUTH HABTOM
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:HABTOM
Last Name:WELDEKRISTOS
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 1:3990 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2097
Mailing Address - Country:US
Mailing Address - Phone:586-260-6154
Mailing Address - Fax:
Practice Address - Street 1:480 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:LASALLE
Practice Address - State:ON
Practice Address - Zip Code:N9J 2H5
Practice Address - Country:CA
Practice Address - Phone:519-258-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272381363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care