Provider Demographics
NPI:1740014281
Name:EZELL, CHANEICE
Entity type:Individual
Prefix:
First Name:CHANEICE
Middle Name:
Last Name:EZELL
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 1:2811 E 119TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2117
Mailing Address - Country:US
Mailing Address - Phone:216-314-1106
Mailing Address - Fax:
Practice Address - Street 1:2811 E 119TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-2117
Practice Address - Country:US
Practice Address - Phone:216-314-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist