Provider Demographics
NPI:1497225478
Name:EBENKAMP, LORI NICOLE (APRN, CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:NICOLE
Last Name:EBENKAMP
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 E MAYFIELD RD STE 115
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2605
Mailing Address - Country:US
Mailing Address - Phone:682-276-6700
Mailing Address - Fax:
Practice Address - Street 1:1915 MAYFIELD ROAD #115
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2605
Practice Address - Country:US
Practice Address - Phone:682-276-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX747314163W00000X
TXAP139365363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28150OtherRX AUTHORIZATION
TXAP139365OtherAPRN
TX747314OtherRN