Provider Demographics
NPI:1164659306
Name:WASHINGTON, EZELLA NEKOLE (DO)
Entity Type:Individual
Prefix:DR
First Name:EZELLA
Middle Name:NEKOLE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 TANK BATTALION
Mailing Address - Street 2:BENNETT MEDICAL CLINIC
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-4906
Mailing Address - Country:US
Mailing Address - Phone:254-618-8040
Mailing Address - Fax:
Practice Address - Street 1:761 TANK BATTALION
Practice Address - Street 2:BENNETT MEDICAL CLINIC
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-4906
Practice Address - Country:US
Practice Address - Phone:254-618-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP60196709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN