Healthcare Provider Details

I. General information

NPI: 1336380591
Provider Name (Legal Business Name): EBONI IFE LANCE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-9150
  • Fax: 443-923-9540
Mailing address:
  • Phone: 443-923-9150
  • Fax: 443-923-9540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0072314
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: