Provider Demographics
NPI:1831935600
Name:OMOTOSHO, EBONY PEARL
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:PEARL
Last Name:OMOTOSHO
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 1:2211 TOWN CENTER DR SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4001
Mailing Address - Country:US
Mailing Address - Phone:571-622-0555
Mailing Address - Fax:
Practice Address - Street 1:2211 TOWN CENTER DR SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4001
Practice Address - Country:US
Practice Address - Phone:571-622-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNA0000607355376K00000X
DCHHA20001252374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide