Provider Demographics
NPI:1649846981
Name:EBAN MILDRED, EBOB
Entity type:Individual
Prefix:
First Name:EBOB
Middle Name:
Last Name:EBAN MILDRED
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 1:780 FAIRVIEW AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-5947
Mailing Address - Country:US
Mailing Address - Phone:404-819-0052
Mailing Address - Fax:
Practice Address - Street 1:780 FAIRVIEW AVE APT 301
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-5947
Practice Address - Country:US
Practice Address - Phone:404-819-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide