Provider Demographics
NPI:1508279837
Name:GRESHAM, EBONEE
Entity type:Individual
Prefix:
First Name:EBONEE
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 257
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-0005
Mailing Address - Country:US
Mailing Address - Phone:678-719-5525
Mailing Address - Fax:
Practice Address - Street 1:4280 MEMORIAL DR STE D
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1216
Practice Address - Country:US
Practice Address - Phone:678-719-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA232368163W00000X
CA95291307163W00000X
OR202205404163W00000X
NY924955163W00000X
HI121515163W00000X
IL041577002163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse