Provider Demographics
NPI:1831926278
Name:MEHERET, ADDISU MAMO
Entity type:Individual
Prefix:
First Name:ADDISU
Middle Name:MAMO
Last Name:MEHERET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 BECONTREE LN APT 1C
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4085
Mailing Address - Country:US
Mailing Address - Phone:571-344-9796
Mailing Address - Fax:
Practice Address - Street 1:1613 BECONTREE LN APT 1C
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4085
Practice Address - Country:US
Practice Address - Phone:571-344-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care