Provider Demographics
NPI:1689207805
Name:KAMONJO, EZEKIEL
Entity Type:Individual
Prefix:
First Name:EZEKIEL
Middle Name:
Last Name:KAMONJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 BENS DR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-5102
Mailing Address - Country:US
Mailing Address - Phone:314-269-3760
Mailing Address - Fax:
Practice Address - Street 1:914 BENS DR
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:TX
Practice Address - Zip Code:75409-5102
Practice Address - Country:US
Practice Address - Phone:314-269-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352345164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse