Provider Demographics
NPI:1306301866
Name:TESSEMA, YETNAYET
Entity type:Individual
Prefix:
First Name:YETNAYET
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 1:400 E SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3184
Mailing Address - Country:US
Mailing Address - Phone:321-722-5200
Mailing Address - Fax:
Practice Address - Street 1:400 E SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3184
Practice Address - Country:US
Practice Address - Phone:321-722-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GARN240416363LF0000X
FLAPRN11020629363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily