Provider Demographics
NPI:1992238240
Name:GEZAHAGN, ETHIOPIA WORKU
Entity type:Individual
Prefix:
First Name:ETHIOPIA
Middle Name:WORKU
Last Name:GEZAHAGN
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 1:1413 RAVENNA CT N
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-1091
Mailing Address - Country:US
Mailing Address - Phone:615-424-4507
Mailing Address - Fax:
Practice Address - Street 1:2221 BEACHFRONT AVE
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-7425
Practice Address - Country:US
Practice Address - Phone:615-424-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN201703240028964251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health