Provider Demographics
NPI:1881906204
Name:EZEMMA, GLORY (RN)
Entity type:Individual
Prefix:
First Name:GLORY
Middle Name:
Last Name:EZEMMA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 QUAKER RD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2828
Mailing Address - Country:US
Mailing Address - Phone:845-406-3062
Mailing Address - Fax:
Practice Address - Street 1:99 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-6026
Practice Address - Country:US
Practice Address - Phone:845-357-4500
Practice Address - Fax:845-357-5039
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY487493163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse