Provider Demographics
NPI:1700581295
Name:HAILU, TSGIE KIDANEMARIAM (LPN)
Entity Type:Individual
Prefix:
First Name:TSGIE
Middle Name:KIDANEMARIAM
Last Name:HAILU
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 DOVER LN APT 204
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-2916
Mailing Address - Country:US
Mailing Address - Phone:703-884-6197
Mailing Address - Fax:
Practice Address - Street 1:4213 WALNEY RD
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2923
Practice Address - Country:US
Practice Address - Phone:703-502-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002099256164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse