Provider Demographics
NPI:1295146926
Name:NELSON, EBONY CHADEL
Entity type:Individual
Prefix:MISS
First Name:EBONY
Middle Name:CHADEL
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 1:725 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-3213
Mailing Address - Country:US
Mailing Address - Phone:353-353-0476
Mailing Address - Fax:
Practice Address - Street 1:725 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615-3213
Practice Address - Country:US
Practice Address - Phone:585-353-0476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY317647Medicaid