Provider Demographics
NPI:1306299268
Name:EZEOLISAH, TINA BETTY (DNP, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:BETTY
Last Name:EZEOLISAH
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 CLAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3405
Mailing Address - Country:US
Mailing Address - Phone:404-636-1457
Mailing Address - Fax:
Practice Address - Street 1:3355 MCDANIEL RD
Practice Address - Street 2:APT 17401
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8613
Practice Address - Country:US
Practice Address - Phone:678-704-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2345725363LP0808X
COC-APN.0002066-C-NP363LP0808X
GARN 217223163W00000X
RI05031363LP0808X
GARN217223363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty