Provider Demographics
NPI:1487164190
Name:EZEALOR, OBINNA (APN PMHNP-BC)
Entity type:Individual
Prefix:
First Name:OBINNA
Middle Name:
Last Name:EZEALOR
Suffix:
Gender:M
Credentials:APN PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 JEROME ST APT E
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-1448
Mailing Address - Country:US
Mailing Address - Phone:908-220-1714
Mailing Address - Fax:
Practice Address - Street 1:1691 US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-1245
Practice Address - Country:US
Practice Address - Phone:732-914-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-08
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00760100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health