Provider Demographics
NPI:1366010324
Name:EZEUDEMBA, CHINENYE EBELE
Entity Type:Individual
Prefix:
First Name:CHINENYE
Middle Name:EBELE
Last Name:EZEUDEMBA
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 1:2040 CAREFREE LN
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3583
Mailing Address - Country:US
Mailing Address - Phone:615-420-5634
Mailing Address - Fax:
Practice Address - Street 1:2040 CAREFREE LN
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3583
Practice Address - Country:US
Practice Address - Phone:615-420-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29479363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health