Provider Demographics
NPI:1508448739
Name:EBOT, LIZETTE MANYI (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LIZETTE
Middle Name:MANYI
Last Name:EBOT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 HEISMAN DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-2838
Mailing Address - Country:US
Mailing Address - Phone:913-219-4321
Mailing Address - Fax:
Practice Address - Street 1:4810 HEISMAN DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-2838
Practice Address - Country:US
Practice Address - Phone:913-219-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1034060363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health