Provider Demographics
NPI:1104334531
Name:AHANONU, EZIHE LORETTA
Entity type:Individual
Prefix:
First Name:EZIHE
Middle Name:LORETTA
Last Name:AHANONU
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 1:1663 EAST 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:718-998-0200
Mailing Address - Fax:718-228-4814
Practice Address - Street 1:1663 EAST 17TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-998-0200
Practice Address - Fax:718-228-4814
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2019-02-19
Deactivation Date:2018-09-02
Deactivation Code:
Reactivation Date:2019-02-18
Provider Licenses
StateLicense IDTaxonomies
NY740752163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY740752OtherREGISTERED PROFESSIONAL NURSE LICENSE