Provider Demographics
NPI:1568582724
Name:ELAM, EBONY MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:MARIE
Last Name:ELAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:EBONY
Other - Middle Name:MARIE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:522 KARL DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2544
Mailing Address - Country:US
Mailing Address - Phone:216-799-1136
Mailing Address - Fax:
Practice Address - Street 1:8701 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6103
Practice Address - Country:US
Practice Address - Phone:440-266-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF0315410363LF0000X
OH17243363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2496062Medicaid