Healthcare Provider Details

I. General information

NPI: 1487461083
Provider Name (Legal Business Name): BENJAMIN D EBAUGH APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 E ROLLINS ST FL 6
ORLANDO FL
32804-5502
US

IV. Provider business mailing address

265 E ROLLINS ST FL 6
ORLANDO FL
32804-5502
US

V. Phone/Fax

Practice location:
  • Phone: 407-821-3586
  • Fax:
Mailing address:
  • Phone: 407-821-3586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11036421
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: