Provider Demographics
NPI:1306468178
Name:WOTICHA, WORKINESH ABDELLA
Entity type:Individual
Prefix:
First Name:WORKINESH
Middle Name:ABDELLA
Last Name:WOTICHA
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 1:493 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-2218
Mailing Address - Country:US
Mailing Address - Phone:651-855-8048
Mailing Address - Fax:651-621-7732
Practice Address - Street 1:493 AURORA AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2218
Practice Address - Country:US
Practice Address - Phone:651-855-8048
Practice Address - Fax:651-621-7732
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1101666374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA773910000OtherDHS