Provider Demographics
NPI:1013516590
Name:TEGEGNE, YOHANNES BERIHUN
Entity Type:Individual
Prefix:
First Name:YOHANNES
Middle Name:BERIHUN
Last Name:TEGEGNE
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 1:6300 STEVENSON AVE APT 613
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-3572
Mailing Address - Country:US
Mailing Address - Phone:703-786-4295
Mailing Address - Fax:
Practice Address - Street 1:11 E LEXINGTON ST STE 600
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-1711
Practice Address - Country:US
Practice Address - Phone:667-260-2933
Practice Address - Fax:410-826-3855
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC002948363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health