Healthcare Provider Details

I. General information

NPI: 1710512041
Provider Name (Legal Business Name): HAMZA EZZENJE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 RANDI DR
AURORA IL
60504-4758
US

IV. Provider business mailing address

318 S 1ST ST APT 1
DEKALB IL
60115-3267
US

V. Phone/Fax

Practice location:
  • Phone: 630-851-7266
  • Fax:
Mailing address:
  • Phone: 217-721-1841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.004633
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: