Provider Demographics
NPI:1841764602
Name:COLE, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:COLE
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 1:204 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7376
Mailing Address - Country:US
Mailing Address - Phone:702-565-1020
Mailing Address - Fax:702-565-1035
Practice Address - Street 1:204 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7376
Practice Address - Country:US
Practice Address - Phone:702-565-1020
Practice Address - Fax:702-565-1035
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1605073477172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver