Healthcare Provider Details

I. General information

NPI: 1003788449
Provider Name (Legal Business Name): EBONY GEBREHAWARIAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 10/24/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 S 31ST ST APT 2307
TEMPLE TX
76504-7147
US

IV. Provider business mailing address

2012 S 31ST ST APT 2307
TEMPLE TX
76504-7147
US

V. Phone/Fax

Practice location:
  • Phone: 737-367-8943
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1034861
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: