Provider Demographics
NPI:1487192548
Name:DEGRAFFENRIED, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:DEGRAFFENRIED
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 1:5683 DUNHAM RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3647
Mailing Address - Country:US
Mailing Address - Phone:216-534-9029
Mailing Address - Fax:
Practice Address - Street 1:5683 DUNHAM RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3647
Practice Address - Country:US
Practice Address - Phone:216-534-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.124715.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse