Healthcare Provider Details

I. General information

NPI: 1245047513
Provider Name (Legal Business Name): EBONI T SAMPSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EBONI TUCKER SAMPSON CRNP

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RAY C HUNT DR
CHARLOTTESVILLE VA
22903-2981
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-2224
  • Fax:
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9641171
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP034182
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR274325
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024196983
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: