Provider Demographics
NPI:1063029957
Name:KEBEDE, DESTA (NP)
Entity type:Individual
Prefix:
First Name:DESTA
Middle Name:
Last Name:KEBEDE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-2010
Mailing Address - Country:US
Mailing Address - Phone:717-231-8265
Mailing Address - Fax:717-221-5219
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-231-8265
Practice Address - Fax:717-221-5219
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022290363LF0000X
GAAPRN-NP332484363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP022290OtherNP LICENSE