Healthcare Provider Details

I. General information

NPI: 1306299268
Provider Name (Legal Business Name): TINA BETTY EZEOLISAH DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 MCDANIEL RD APT 17401
DULUTH GA
30096-8613
US

IV. Provider business mailing address

1814 CLAIRMONT RD
DECATUR GA
30033-3405
US

V. Phone/Fax

Practice location:
  • Phone: 678-704-3593
  • Fax:
Mailing address:
  • Phone: 404-636-1457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2345725
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0002066-C-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 217223
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number05031
License Number StateRI
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN217223
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: