Provider Demographics
NPI:1750981148
Name:AMSALLU, YETAYESH
Entity type:Individual
Prefix:
First Name:YETAYESH
Middle Name:
Last Name:AMSALLU
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 1:1909 MERRIMAC DR
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2243
Mailing Address - Country:US
Mailing Address - Phone:301-920-4155
Mailing Address - Fax:
Practice Address - Street 1:1909 MERRIMAC DR
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-2243
Practice Address - Country:US
Practice Address - Phone:301-920-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00182473Medicaid