Provider Demographics
NPI:1851046411
Name:EZEAMAMA, CHARITY C
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:C
Last Name:EZEAMAMA
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:714-443-4512
Mailing Address - Fax:
Practice Address - Street 1:22635 ALESSANDRO BLVD STE A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8550
Practice Address - Country:US
Practice Address - Phone:951-242-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant