Provider Demographics
NPI:1033706403
Name:EZELL, ANTOINETTA E
Entity type:Individual
Prefix:
First Name:ANTOINETTA
Middle Name:E
Last Name:EZELL
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 1:4126 KINGSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1609
Mailing Address - Country:US
Mailing Address - Phone:419-917-1698
Mailing Address - Fax:
Practice Address - Street 1:4126 KINGSBURY AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1609
Practice Address - Country:US
Practice Address - Phone:419-917-1698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0347991Medicaid