Provider Demographics
NPI:1609009828
Name:EZEIBE, KINGSLEY NNAOMA (LVN)
Entity Type:Individual
Prefix:MR
First Name:KINGSLEY
Middle Name:NNAOMA
Last Name:EZEIBE
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:MR
Other - First Name:KINGSLEY
Other - Middle Name:NNAOMA
Other - Last Name:EZEIBE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:15500 S BUDLONG PL
Mailing Address - Street 2:APT 10
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4055
Mailing Address - Country:US
Mailing Address - Phone:310-329-6171
Mailing Address - Fax:
Practice Address - Street 1:15500 S BUDLONG PL
Practice Address - Street 2:APT 10
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4055
Practice Address - Country:US
Practice Address - Phone:310-329-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN225606164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse