Provider Demographics
NPI:1295125631
Name:TECLEAB, FESSEHAIE
Entity type:Individual
Prefix:DR
First Name:FESSEHAIE
Middle Name:
Last Name:TECLEAB
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 1:102 KEATING CIRCLE
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:703-768-7044
Mailing Address - Fax:703-768-1080
Practice Address - Street 1:1636 BELLEVUE BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307
Practice Address - Country:US
Practice Address - Phone:703-768-7044
Practice Address - Fax:703-768-1080
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA020205272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist