MEDICARE: DR. EDITH IFEYINWA EZEKWE RDN, ASCP,

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian	914536	MS

General Provider Information

NPI Number	:	1578377404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDITH IFEYINWA EZEKWE RDN, ASCP,

Provider Business Mailing Address
First Line	:	123 BROOKWOOD DR
Second Line	:
City	:	VICKSBURG
State	:	MS
Zip	:	39183-1622
Country	:	US
Telephone Number	:	601-415-1249
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 FARMER ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2319
Country	:	US
Telephone Number	:	601-437-5668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2025
Last Update Date	:	02/03/2025

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