Provider Demographics
NPI:1609921568
Name:EZEANI, ROSE NKOLI (NP)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:NKOLI
Last Name:EZEANI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MONTAUK HWY STE 2-4
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4910
Mailing Address - Country:US
Mailing Address - Phone:631-647-9100
Mailing Address - Fax:631-647-9099
Practice Address - Street 1:1111 MONTAUK HWY STE 2-4
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4910
Practice Address - Country:US
Practice Address - Phone:631-647-9100
Practice Address - Fax:631-647-9099
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303867363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health