Healthcare Provider Details

I. General information

NPI: 1508279837
Provider Name (Legal Business Name): EBONEE GRESHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4280 MEMORIAL DR STE D
DECATUR GA
30032-1216
US

IV. Provider business mailing address

PO BOX 257
GRAYSON GA
30017-0005
US

V. Phone/Fax

Practice location:
  • Phone: 678-719-5525
  • Fax:
Mailing address:
  • Phone: 678-719-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP232368
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number121515
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number232368
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041577002
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number202205404
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95291307
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number924955
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: