1588091276 NPI number — MS. AYO RENEE EZEAMAMA MSN

Table of content: MS. AYO RENEE EZEAMAMA MSN (NPI 1588091276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588091276 NPI number — MS. AYO RENEE EZEAMAMA MSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EZEAMAMA
Provider First Name:
AYO
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588091276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 BERING DR APT 609
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77057-3729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-203-3272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 PARK LN
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-658-5230
Provider Business Practice Location Address Fax Number:
713-473-0385
Provider Enumeration Date:
09/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209010758 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: AP126407 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3491375 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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