Provider Demographics
NPI:1245982370
Name:NELSON, EBONI NICOLE
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:NICOLE
Last Name:NELSON
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 1:1173 S PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2311
Mailing Address - Country:US
Mailing Address - Phone:810-743-1007
Mailing Address - Fax:810-462-1093
Practice Address - Street 1:1173 S PACKARD AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-2311
Practice Address - Country:US
Practice Address - Phone:810-743-1007
Practice Address - Fax:810-462-1093
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker