Healthcare Provider Details

I. General information

NPI: 1285220764
Provider Name (Legal Business Name): KENECHUKWU EZEANYA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FRANKLIN SQUARE DR STE 410
SOMERSET NJ
08873-4109
US

IV. Provider business mailing address

100 FRANKLIN SQUARE DR STE 410
SOMERSET NJ
08873-4109
US

V. Phone/Fax

Practice location:
  • Phone: 732-558-9625
  • Fax: 973-548-9450
Mailing address:
  • Phone: 732-558-9625
  • Fax: 973-548-9450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15281600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code364SP0813X
TaxonomyGeropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
License Number26NJ15281600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: