Provider Demographics
NPI:1225571805
Name:EZELL, MELISSA DELAINE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DELAINE
Last Name:EZELL
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 1:29140 E 156TH ST S
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-4122
Mailing Address - Country:US
Mailing Address - Phone:918-402-2556
Mailing Address - Fax:
Practice Address - Street 1:29140 E 156TH ST S
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-4122
Practice Address - Country:US
Practice Address - Phone:918-402-2556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management