Provider Demographics
NPI:1225864663
Name:TADESSE, REDIAT
Entity type:Individual
Prefix:
First Name:REDIAT
Middle Name:
Last Name:TADESSE
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 1:12213 OLD FORT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-2714
Mailing Address - Country:US
Mailing Address - Phone:571-344-4809
Mailing Address - Fax:
Practice Address - Street 1:12213 OLD FORT RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-2714
Practice Address - Country:US
Practice Address - Phone:571-344-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAL-00288310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility