Provider Demographics
NPI:1164179461
Name:WEST, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 CEDARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-1607
Mailing Address - Country:US
Mailing Address - Phone:574-904-4212
Mailing Address - Fax:
Practice Address - Street 1:5122 CEDARWOOD LN
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-1607
Practice Address - Country:US
Practice Address - Phone:574-904-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21-015359-13747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant