Provider Demographics
NPI:1922601889
Name:EBOM, MARYANN
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:EBOM
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 1:3240 186TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2798
Mailing Address - Country:US
Mailing Address - Phone:708-957-3101
Mailing Address - Fax:708-991-2253
Practice Address - Street 1:18225 BURNHAM AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-3059
Practice Address - Country:US
Practice Address - Phone:708-957-3101
Practice Address - Fax:708-991-2253
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILF10201531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty