Provider Demographics
NPI:1669293486
Name:COLEMAN, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:COLEMAN
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 1:3337 AVENUE VILLANDRY
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-2220
Mailing Address - Country:US
Mailing Address - Phone:561-843-6586
Mailing Address - Fax:
Practice Address - Street 1:3337 AVENUE VILLANDRY
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-2220
Practice Address - Country:US
Practice Address - Phone:561-843-6586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization