Healthcare Provider Details

I. General information

NPI: 1497225478
Provider Name (Legal Business Name): LORI NICOLE EBENKAMP APRN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 MAYFIELD ROAD #115
ARLINGTON TX
76014-2605
US

IV. Provider business mailing address

1915 E MAYFIELD RD STE 115
ARLINGTON TX
76014-2605
US

V. Phone/Fax

Practice location:
  • Phone: 682-276-6700
  • Fax:
Mailing address:
  • Phone: 682-276-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number747314
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP139365
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: