Provider Demographics
NPI:1821620840
Name:EZEKIEL, AGNES OLAOLU (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:OLAOLU
Last Name:EZEKIEL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1231
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-1231
Mailing Address - Country:US
Mailing Address - Phone:406-262-1302
Mailing Address - Fax:406-265-1651
Practice Address - Street 1:1545 HARBECK RD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5605
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT162006363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health