Provider Demographics
NPI:1003463746
Name:EZELI, DIAMOND
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:EZELI
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 1:1825 SOUTHCROSS DR W APT 2303
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7976
Mailing Address - Country:US
Mailing Address - Phone:651-263-9543
Mailing Address - Fax:
Practice Address - Street 1:1825 SOUTHCROSS DR W APT 2303
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7976
Practice Address - Country:US
Practice Address - Phone:651-263-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN391528374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide