Provider Demographics
NPI:1902525181
Name:EZEUDU, FEHINTOLA
Entity Type:Individual
Prefix:
First Name:FEHINTOLA
Middle Name:
Last Name:EZEUDU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 CHANDLER WAY DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8163
Mailing Address - Country:US
Mailing Address - Phone:404-512-5956
Mailing Address - Fax:
Practice Address - Street 1:1126 CHANDLER WAY DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8163
Practice Address - Country:US
Practice Address - Phone:404-512-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA230957363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care