Provider Demographics
NPI:1235482720
Name:MOULTRY, EBONY NICOLE (STNA)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:NICOLE
Last Name:MOULTRY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3363 E 123RD ST
Mailing Address - Street 2:APT. DOWN
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-3851
Mailing Address - Country:US
Mailing Address - Phone:216-659-9638
Mailing Address - Fax:
Practice Address - Street 1:3363 E 123RD ST
Practice Address - Street 2:APT. DOWN
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-3851
Practice Address - Country:US
Practice Address - Phone:216-659-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-21
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401399400612376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide