Provider Demographics
NPI:1457816969
Name:EBESOH, MELVIS
Entity Type:Individual
Prefix:
First Name:MELVIS
Middle Name:
Last Name:EBESOH
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 1:509 CRETIA PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5787
Mailing Address - Country:US
Mailing Address - Phone:240-713-8026
Mailing Address - Fax:
Practice Address - Street 1:509 CRETIA PL
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5787
Practice Address - Country:US
Practice Address - Phone:240-713-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14281374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide