Provider Demographics
NPI:1932505757
Name:EZEKOYE, DIANE R (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:R
Last Name:EZEKOYE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:R
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1830 GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1233
Practice Address - Country:US
Practice Address - Phone:717-732-8877
Practice Address - Fax:717-732-9241
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014145363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103046285Medicaid
PA103046285Medicaid