Provider Demographics
NPI:1689454696
Name:ISAACS, EBONI NICOEL (HLP)
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:NICOEL
Last Name:ISAACS
Suffix:
Gender:F
Credentials:HLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 VALE AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2160
Mailing Address - Country:US
Mailing Address - Phone:513-608-6599
Mailing Address - Fax:
Practice Address - Street 1:11711 PRINCETON PIKE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-2534
Practice Address - Country:US
Practice Address - Phone:513-608-6599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOSA.980771207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty