Provider Demographics
NPI:1619798345
Name:EZELL, JOQUETTA (HOME CARE AIDE)
Entity type:Individual
Prefix:
First Name:JOQUETTA
Middle Name:
Last Name:EZELL
Suffix:
Gender:F
Credentials:HOME CARE AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 MARKET ST # M2
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3737
Mailing Address - Country:US
Mailing Address - Phone:206-478-6796
Mailing Address - Fax:
Practice Address - Street 1:748 MARKET ST # M2
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3737
Practice Address - Country:US
Practice Address - Phone:206-478-6796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHM61136119374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty