Provider Demographics
NPI:1144972225
Name:WASHINGTON, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HERBALIST
Mailing Address - Street 1:5622 PACIFIC AVE SE STE 6
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1271
Mailing Address - Country:US
Mailing Address - Phone:360-915-7944
Mailing Address - Fax:
Practice Address - Street 1:5622 PACIFIC AVE SE STE 6
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1271
Practice Address - Country:US
Practice Address - Phone:360-915-7944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604564948171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach