Provider Demographics
NPI:1497090633
Name:POINDEXTER, EBONY WILLIAMS (LMT)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:WILLIAMS
Last Name:POINDEXTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 WHITLEY ABBEY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-5753
Mailing Address - Country:US
Mailing Address - Phone:757-749-2209
Mailing Address - Fax:
Practice Address - Street 1:228 N LYNNHAVEN RD
Practice Address - Street 2:SUITE 107
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7514
Practice Address - Country:US
Practice Address - Phone:757-340-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA919643436172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker