Provider Demographics
NPI:1134608607
Name:MENGISTE, MIKYAS GETACHEW
Entity type:Individual
Prefix:
First Name:MIKYAS
Middle Name:GETACHEW
Last Name:MENGISTE
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 1:905 VARNUM ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-7135
Mailing Address - Country:US
Mailing Address - Phone:240-408-6770
Mailing Address - Fax:
Practice Address - Street 1:824 UPSHUR ST NW APT 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5837
Practice Address - Country:US
Practice Address - Phone:202-723-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13850374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide