Provider Demographics
NPI:1578297313
Name:CHATMON, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:CHATMON
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:PO BOX
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-2514
Mailing Address - Country:US
Mailing Address - Phone:215-315-8665
Mailing Address - Fax:
Practice Address - Street 1:376 2ND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3834
Practice Address - Country:US
Practice Address - Phone:215-315-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner