Provider Demographics
NPI:1376282608
Name:EZECHUKWU, ADAOLISA
Entity Type:Individual
Prefix:
First Name:ADAOLISA
Middle Name:
Last Name:EZECHUKWU
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 1:1009 29TH AVE SE APT A
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2745
Mailing Address - Country:US
Mailing Address - Phone:484-716-6046
Mailing Address - Fax:
Practice Address - Street 1:1009 29TH AVE SE APT A
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2745
Practice Address - Country:US
Practice Address - Phone:484-716-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program