Provider Demographics
NPI:1497639140
Name:EZENNIA, CLARIBELL
Entity type:Individual
Prefix:
First Name:CLARIBELL
Middle Name:
Last Name:EZENNIA
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 1:1240 3RD AVE E STE 100
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 3RD AVE E STE 100
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1679
Practice Address - Country:US
Practice Address - Phone:952-777-4996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-09-11
Deactivation Date:2025-08-16
Deactivation Code:
Reactivation Date:2025-09-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency