Provider Demographics
NPI:1871821926
Name:BELAY, KASSA TADESSE
Entity Type:Individual
Prefix:
First Name:KASSA
Middle Name:TADESSE
Last Name:BELAY
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 1:5558 MALIBU DR
Mailing Address - Street 2:APT C
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3660
Mailing Address - Country:US
Mailing Address - Phone:614-861-4701
Mailing Address - Fax:
Practice Address - Street 1:5558 MALIBU DR
Practice Address - Street 2:APT C
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3660
Practice Address - Country:US
Practice Address - Phone:614-861-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.118354164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse