Provider Demographics
NPI:1285224618
Name:EZETENDU, ADEBOLA
Entity Type:Individual
Prefix:
First Name:ADEBOLA
Middle Name:
Last Name:EZETENDU
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 1:5479 STONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-1679
Mailing Address - Country:US
Mailing Address - Phone:281-948-2545
Mailing Address - Fax:
Practice Address - Street 1:5500 RIDGE RD STE 120
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-2367
Practice Address - Country:US
Practice Address - Phone:216-202-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028258363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care