Healthcare Provider Details

I. General information

NPI: 1073231353
Provider Name (Legal Business Name): IHN PODIATRY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5304 S FLORIDA AVE STE 406
LAKELAND FL
33813-4914
US

IV. Provider business mailing address

5304 S FLORIDA AVE STE 400F
LAKELAND FL
33813-4914
US

V. Phone/Fax

Practice location:
  • Phone: 863-738-6601
  • Fax:
Mailing address:
  • Phone: 863-738-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MRS. GLORIED EBSWORTH
Title or Position: PROVIDER
Credential: DPM
Phone: 305-781-9667