Provider Demographics
NPI:1730545575
Name:EBONG, SIMON
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:EBONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 FOX ST
Mailing Address - Street 2:APT. 203
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1806 FOX ST
Practice Address - Street 2:APT. 203
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-2352
Practice Address - Country:US
Practice Address - Phone:912-996-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11755374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide