Provider Demographics
NPI:1366152712
Name:HUNACHEW, KIDIST
Entity type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:HUNACHEW
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 1:26 LEWALLEN DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-2249
Mailing Address - Country:US
Mailing Address - Phone:202-642-8881
Mailing Address - Fax:
Practice Address - Street 1:26 LEWALLEN DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-2249
Practice Address - Country:US
Practice Address - Phone:202-642-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT58071614172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver