Provider Demographics
NPI:1679040208
Name:NELSON, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:NELSON
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 1:3914 SUSANNA RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4056
Mailing Address - Country:US
Mailing Address - Phone:443-297-9171
Mailing Address - Fax:
Practice Address - Street 1:6031 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-6206
Practice Address - Country:US
Practice Address - Phone:443-297-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD408932207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology