Provider Demographics
NPI:1851046411
Name:EZEAMAMA, CHARITY C
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:C
Last Name:EZEAMAMA
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 1:10216 S DENKER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-4205
Mailing Address - Country:US
Mailing Address - Phone:909-268-4181
Mailing Address - Fax:
Practice Address - Street 1:2979 MUMFORD CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-8807
Practice Address - Country:US
Practice Address - Phone:909-268-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant