Provider Demographics
NPI:1700593811
Name:AYELE, TEDBABEWORK M
Entity Type:Individual
Prefix:
First Name:TEDBABEWORK
Middle Name:M
Last Name:AYELE
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 1:2168 QUAIL CREEK PKWY NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-3901
Mailing Address - Country:US
Mailing Address - Phone:612-296-2757
Mailing Address - Fax:
Practice Address - Street 1:324 E 35TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4580
Practice Address - Country:US
Practice Address - Phone:612-827-7181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9622363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care