Provider Demographics
NPI:1164853503
Name:EBBLIE, JOAN ELLEN (LAC, RN)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:ELLEN
Last Name:EBBLIE
Suffix:
Gender:F
Credentials:LAC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29690 STATE RT. 180
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-658-2110
Mailing Address - Fax:
Practice Address - Street 1:29690 STATE RT. 180
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-658-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274794-1163WG0000X
NY003092-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice