1568582724 NPI number — MRS. EBONY MARIE ELAM NP

Table of content: MRS. EBONY MARIE ELAM NP (NPI 1568582724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568582724 NPI number — MRS. EBONY MARIE ELAM NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELAM
Provider First Name:
EBONY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
EBONY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C, PMHNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568582724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
466 TREBISKY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND HTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44143-2823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-799-1136
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5294 MAYFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNDHURST
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44124-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-799-1136
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F0315410 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 17243 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2496062 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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