Provider Demographics
NPI:1487072468
Name:LEGESSE, YESHEWAGET
Entity type:Individual
Prefix:
First Name:YESHEWAGET
Middle Name:
Last Name:LEGESSE
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 1:4700 MILLENIA BLVD STE 650
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6013
Mailing Address - Country:US
Mailing Address - Phone:469-936-0541
Mailing Address - Fax:877-708-4417
Practice Address - Street 1:1205 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5835
Practice Address - Country:US
Practice Address - Phone:469-936-0541
Practice Address - Fax:877-708-4417
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX646931363L00000X, 364SG0600X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care