Provider Demographics
NPI:1780275693
Name:TESSEMA, KIDIST
Entity type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:TESSEMA
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 1:1440 ROCK CREEK FORD RD NW APT 214
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1756
Mailing Address - Country:US
Mailing Address - Phone:504-505-2230
Mailing Address - Fax:
Practice Address - Street 1:1440 ROCK CREEK FORD RD NW APT 214
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1756
Practice Address - Country:US
Practice Address - Phone:504-505-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15522163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health