Provider Demographics
NPI:1962193136
Name:EZEH, IFEOMA (N/A)
Entity type:Individual
Prefix:
First Name:IFEOMA
Middle Name:
Last Name:EZEH
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:IFEOMA
Other - Middle Name:
Other - Last Name:EZEH ANYIKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:3372 VICTORY BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6795
Mailing Address - Country:US
Mailing Address - Phone:347-784-0236
Mailing Address - Fax:
Practice Address - Street 1:3372 VICTORY BLVD FL 2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6795
Practice Address - Country:US
Practice Address - Phone:347-784-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1693491231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist