Provider Demographics
NPI:1679192983
Name:ADDISON, EBONI PAYTON (MSN APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:PAYTON
Last Name:ADDISON
Suffix:
Gender:F
Credentials:MSN APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 ANCHOR DR
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-6081
Mailing Address - Country:US
Mailing Address - Phone:504-292-5057
Mailing Address - Fax:
Practice Address - Street 1:1101 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3147
Practice Address - Country:US
Practice Address - Phone:504-347-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA212096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2521799Medicaid