Healthcare Provider Details

I. General information

NPI: 1740014281
Provider Name (Legal Business Name): CHANEICE EZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 E 119TH ST
CLEVELAND OH
44120-2117
US

IV. Provider business mailing address

2811 E 119TH ST
CLEVELAND OH
44120-2117
US

V. Phone/Fax

Practice location:
  • Phone: 216-314-1106
  • Fax:
Mailing address:
  • Phone: 216-314-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: