Healthcare Provider Details

I. General information

NPI: 1972309904
Provider Name (Legal Business Name): MS. EBONY LACHE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10530 CAMPUS WAY S STE 1223
UPPER MARLBORO MD
20774-1309
US

IV. Provider business mailing address

10530 CAMPUS WAY S STE 1223
UPPER MARLBORO MD
20774-1309
US

V. Phone/Fax

Practice location:
  • Phone: 888-912-5922
  • Fax:
Mailing address:
  • Phone: 888-912-5922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: