Provider Demographics
NPI:1780381194
Name:EZE, MARIAH
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:EZE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 FORTUNA CENTER PLZ STE 607
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1515
Mailing Address - Country:US
Mailing Address - Phone:703-789-5224
Mailing Address - Fax:
Practice Address - Street 1:15262 FLINTLOCK TER
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3829
Practice Address - Country:US
Practice Address - Phone:703-789-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186469363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty