Provider Demographics
NPI:1376315085
Name:BANKSTON-KING, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:BANKSTON-KING
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 1:166 BARRY AVE
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:166 BARRY AVE
Practice Address - Street 2:
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9707
Practice Address - Country:US
Practice Address - Phone:501-710-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA442324376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide