Healthcare Provider Details

I. General information

NPI: 1205452935
Provider Name (Legal Business Name): EZINNE KANU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: N/A N/A

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 11/04/2023
Certification Date: 11/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 SAINT SEBASTIAN WAY
AUGUSTA GA
30912-2613
US

IV. Provider business mailing address

1480 WRIGHTSBORO RD APT 1326
AUGUSTA GA
30901-3209
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6715
  • Fax:
Mailing address:
  • Phone: 214-864-1746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023044187
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number96873
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: