Provider Demographics
NPI:1699436923
Name:MENGISTU, SELAM
Entity type:Individual
Prefix:
First Name:SELAM
Middle Name:
Last Name:MENGISTU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 GILMER ST SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 GILMER ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3044
Practice Address - Country:US
Practice Address - Phone:404-413-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2025-04-22
Deactivation Date:2024-08-06
Deactivation Code:
Reactivation Date:2024-08-23
Provider Licenses
StateLicense IDTaxonomies
GA212292363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health