MEDICARE: EBONI DAVIS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	4704293548	MI
2	363LF0000X	Family Nurse Practitioner	APRN9493752	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578960878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONI DAVIS APRN

Provider Business Mailing Address
First Line	:	1192 E NEWPORT CENTER DR
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-7753
Country	:	US
Telephone Number	:	954-571-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1192 E NEWPORT CENTER DR
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-7753
Country	:	US
Telephone Number	:	954-571-0111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2014
Last Update Date	:	09/11/2019

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