Healthcare Provider Details

I. General information

NPI: 1922601889
Provider Name (Legal Business Name): MARYANN EBOM DNP, PMHNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18225 BURNHAM AVE
LANSING IL
60438-3059
US

IV. Provider business mailing address

3240 186TH ST
HOMEWOOD IL
60430-2798
US

V. Phone/Fax

Practice location:
  • Phone: 708-957-3101
  • Fax: 708-991-2253
Mailing address:
  • Phone: 708-957-3101
  • Fax: 708-991-2253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10201531
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: