Provider Demographics
NPI:1104329218
Name:EZEIGWE, IFEOMA JULIET (NP)
Entity type:Individual
Prefix:
First Name:IFEOMA
Middle Name:JULIET
Last Name:EZEIGWE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-7735
Mailing Address - Country:US
Mailing Address - Phone:903-593-1246
Mailing Address - Fax:903-593-1246
Practice Address - Street 1:601 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-7735
Practice Address - Country:US
Practice Address - Phone:903-593-1246
Practice Address - Fax:903-593-1246
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133917363LA2200X, 363LP0808X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health