Healthcare Provider Details

I. General information

NPI: 1043141864
Provider Name (Legal Business Name): CHARLENE STEPHANIE EBILANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 E MARKET AVE
SEARCY AR
72149-5615
US

IV. Provider business mailing address

128 W 226TH PL
CARSON CA
90745-3713
US

V. Phone/Fax

Practice location:
  • Phone: 501-279-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: