Provider Demographics
NPI:1255683967
Name:SMITH, EBONY M (LPN)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 INTERCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-7417
Mailing Address - Country:US
Mailing Address - Phone:910-964-5642
Mailing Address - Fax:
Practice Address - Street 1:328 INTERCHANGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-7417
Practice Address - Country:US
Practice Address - Phone:910-964-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73712164W00000X
NY280956-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse