Healthcare Provider Details

I. General information

NPI: 1497618730
Provider Name (Legal Business Name): EBONEE ROSE BLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 GILMAN RD
COLUMBUS OH
43228-6471
US

IV. Provider business mailing address

4604 GILMAN RD
COLUMBUS OH
43228-6471
US

V. Phone/Fax

Practice location:
  • Phone: 614-371-2645
  • Fax:
Mailing address:
  • Phone: 614-371-2645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberVQ610186
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: