Provider Demographics
NPI:1780380634
Name:EZEOKE, RIVER-JEANETTE MONIQUE (CPRS)
Entity type:Individual
Prefix:
First Name:RIVER-JEANETTE
Middle Name:MONIQUE
Last Name:EZEOKE
Suffix:
Gender:F
Credentials:CPRS
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 343
Mailing Address - Street 2:
Mailing Address - City:WILLERNIE
Mailing Address - State:MN
Mailing Address - Zip Code:55090-0343
Mailing Address - Country:US
Mailing Address - Phone:612-601-4549
Mailing Address - Fax:
Practice Address - Street 1:2511 CROIXWOOD BLVD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:612-601-4549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8661175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty