Provider Demographics
NPI:1295367696
Name:CAMPBELL, EBONE LE TRICE
Entity Type:Individual
Prefix:
First Name:EBONE
Middle Name:LE TRICE
Last Name:CAMPBELL
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 1:1818 ALABAMA AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-2810
Mailing Address - Country:US
Mailing Address - Phone:202-315-7846
Mailing Address - Fax:
Practice Address - Street 1:1711 BENNING RD NE APT F14
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7250
Practice Address - Country:US
Practice Address - Phone:202-487-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC19952043747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant