Provider Demographics
NPI:1356032262
Name:FISSEHA, KIDIST
Entity type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:FISSEHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 W INNOVATION WAY FL 4
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4252
Mailing Address - Country:US
Mailing Address - Phone:855-726-6363
Mailing Address - Fax:801-784-1482
Practice Address - Street 1:1633 W INNOVATION WAY FL 4
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4252
Practice Address - Country:US
Practice Address - Phone:855-726-6363
Practice Address - Fax:801-784-1482
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1009883163W00000X
UT9115682-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse