Provider Demographics
NPI:1699918722
Name:EZEH, AUDREY N (CRNA, MSN)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:N
Last Name:EZEH
Suffix:
Gender:F
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:EZEIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3949 S COBB DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6342
Mailing Address - Country:US
Mailing Address - Phone:770-434-0710
Mailing Address - Fax:
Practice Address - Street 1:3949 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6342
Practice Address - Country:US
Practice Address - Phone:770-434-0710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202850174400000X
GARN225327367500000X
MARN2265022367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist