Tina Betty Ezeolisah, DNP, PMHNP-BC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

RN217223 Issued in GA

Practice address

3355 McDaniel Rd
Apt 17401
Duluth, GA 30096-8613

Phone

(678) 704-3593

NPI assigned

Jul 15, 2016

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 5

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Highland Rivers Community Service Board

  • Community/Behavioral Health Agency
  • Dalton, GA
  • NPI 1447256243

  Multi-Specialty

  Medicare reassignment NPD
• Personal Recovery Network LLC

  • Psychiatry Physician
  • Stockbridge, GA
  • NPI 1881990869

  Multi-Specialty

  Medicare reassignment NPD
• Highland Rivers CSB

  • Community/Behavioral Health Agency
  • Dalton, GA
  • NPI 1164585543
  NPD
• Pamphra Psychotherapy LLC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Atlanta, GA
  • NPI 1588401319
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1468540800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1669939200000",
    "number": "1306299268",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1814 CLAIRMONT RD",
            "city": "DECATUR",
            "state": "GA",
            "postal_code": "300333405",
            "telephone_number": "404-636-1457"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3355 MCDANIEL RD",
            "address_2": "APT 17401",
            "city": "DULUTH",
            "state": "GA",
            "postal_code": "300968613",
            "telephone_number": "678-704-3593"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "940 Concord Rd SE",
            "address_purpose": "LOCATION",
            "city": "Smyrna",
            "state": "GA",
            "postal_code": "300804204",
            "country_code": "US",
            "telephone_number": "404-636-1457",
            "fax_number": "404-636-7449",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1814 Clairmont Rd",
            "address_purpose": "LOCATION",
            "city": "Decatur",
            "state": "GA",
            "postal_code": "300333405",
            "country_code": "US",
            "telephone_number": "404-636-1457",
            "fax_number": "404-636-7449",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "EZEOLISAH",
        "first_name": "TINA",
        "middle_name": "BETTY",
        "name_prefix": "Dr.",
        "credential": "DNP, PMHNP-BC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2016-07-15",
        "last_updated": "2022-12-02",
        "certification_date": "2022-12-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "MA",
            "license": "RN2345725",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "CO",
            "license": "C-APN.0002066-C-NP",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "GA",
            "license": "RN 217223",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "RI",
            "license": "05031",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "GA",
            "license": "RN217223",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Express Clinic, LLC
• Express Pharmacy Inc
• Eye Galleria
• Eye Site of Duluth, Inc
• Eye1St Vision & Laser, LLC
• Tarayn Alessandra Fairlie, MD MPH
• Seema Faiyaz
• April Elizabeth Fallon, LCSW
• Khadija Falloon
• Familee'S Pharmacy

• Psychiatric/Mental Health Nurse Practitioner in Duluth, GA
• Providers in Duluth, GA by specialty
• Psychiatric/Mental Health Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.