Provider Demographics
NPI:1912641879
Name:MORA, EZEQUIEL R (APRN FNP-BC)
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:R
Last Name:MORA
Suffix:
Gender:M
Credentials:APRN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 OMEGA CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-5832
Mailing Address - Country:US
Mailing Address - Phone:815-501-5393
Mailing Address - Fax:
Practice Address - Street 1:954 W STATE ST
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-1335
Practice Address - Country:US
Practice Address - Phone:815-895-9144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.408204363LF0000X
IL209.025250363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily