Provider Demographics
NPI:1740803188
Name:EBERLY, CHESEDA RIVKAH
Entity Type:Individual
Prefix:
First Name:CHESEDA
Middle Name:RIVKAH
Last Name:EBERLY
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 1:4804 BLUE TOP DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4369
Mailing Address - Country:US
Mailing Address - Phone:817-773-6473
Mailing Address - Fax:
Practice Address - Street 1:4804 BLUE TOP DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-4369
Practice Address - Country:US
Practice Address - Phone:817-773-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX765445163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse