Provider Demographics
NPI:1962195495
Name:MENGSTIE, SISAY
Entity type:Individual
Prefix:
First Name:SISAY
Middle Name:
Last Name:MENGSTIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 167TH PL SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8023
Mailing Address - Country:US
Mailing Address - Phone:206-697-8330
Mailing Address - Fax:
Practice Address - Street 1:2507 167TH PL SE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-8023
Practice Address - Country:US
Practice Address - Phone:206-697-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide