Provider Demographics
NPI:1982096376
Name:MAMO, YEMESERACH W
Entity Type:Individual
Prefix:
First Name:YEMESERACH
Middle Name:W
Last Name:MAMO
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 1:1220 12TH ST NW APT 612
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-4333
Mailing Address - Country:US
Mailing Address - Phone:202-817-4206
Mailing Address - Fax:
Practice Address - Street 1:1822 JEFFERSON PL NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-2505
Practice Address - Country:US
Practice Address - Phone:202-293-2937
Practice Address - Fax:202-293-3480
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11051374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide