Healthcare Provider Details

I. General information

NPI: 1528805496
Provider Name (Legal Business Name): EBONI DOMINIQUE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 N BLACKSTONE AVE
FRESNO CA
93726-3808
US

IV. Provider business mailing address

4141 N BLACKSTONE AVE
FRESNO CA
93726-3808
US

V. Phone/Fax

Practice location:
  • Phone: 559-579-1744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-JMHWOX
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: