Provider Demographics
NPI:1295346690
Name:FISSIHA, YOHANNES
Entity type:Individual
Prefix:
First Name:YOHANNES
Middle Name:
Last Name:FISSIHA
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 1:401 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4444
Mailing Address - Country:US
Mailing Address - Phone:386-761-6268
Mailing Address - Fax:
Practice Address - Street 1:401 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4444
Practice Address - Country:US
Practice Address - Phone:386-767-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6084310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility