Healthcare Provider Details

I. General information

NPI: 1639882426
Provider Name (Legal Business Name): DR. EBONI SHAVONE RAINEY-HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EBONI S RAINEY DR

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 W STATE ROAD 436 STE 1005
ALTAMONTE SPRINGS FL
32714-3055
US

IV. Provider business mailing address

851 W STATE ROAD 436 STE 1005
ALTAMONTE SPRINGS FL
32714-3055
US

V. Phone/Fax

Practice location:
  • Phone: 407-383-0643
  • Fax: 407-266-0977
Mailing address:
  • Phone: 407-383-0643
  • Fax: 407-266-0977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFB9767225
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: