Basic Information
Provider Information | |||||||||
NPI: | 1932505757 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EZEKOYE | ||||||||
FirstName: | DIANE | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEAN | ||||||||
OtherFirstName: | DIANE | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 409 S 2ND ST STE 2F | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171041612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1830 GOOD HOPE RD | ||||||||
Address2: |   | ||||||||
City: | ENOLA | ||||||||
State: | PA | ||||||||
PostalCode: | 170251233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177328877 | ||||||||
FaxNumber: | 7177329241 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2014 | ||||||||
LastUpdateDate: | 01/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP014145 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 103046285 | 05 | PA |   | MEDICAID |