Healthcare Provider Details

I. General information

NPI: 1336064229
Provider Name (Legal Business Name): EBONY MARIE LOVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

12571 WEBSTER CT
CHINO CA
91710-3551
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1000
  • Fax:
Mailing address:
  • Phone: 310-402-7354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95040891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: