Provider Demographics
NPI:1184994105
Name:KEDEDA, BERHANU EJIGU (NP-C)
Entity type:Individual
Prefix:
First Name:BERHANU
Middle Name:EJIGU
Last Name:KEDEDA
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:BERHANU
Other - Middle Name:KEDIDA
Other - Last Name:EJIGU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:5576 PRINCETON RUN TRL
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8463
Mailing Address - Country:US
Mailing Address - Phone:678-793-8808
Mailing Address - Fax:
Practice Address - Street 1:5576 PRINCETON RUN TRL
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8463
Practice Address - Country:US
Practice Address - Phone:678-793-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN152429363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily