Healthcare Provider Details

I. General information

NPI: 1376938209
Provider Name (Legal Business Name): EBONIE MYAKEE ZOLLICOFFER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2015
Last Update Date: 05/25/2020
Certification Date: 05/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N62W23334 SILVER SPRING DR
SUSSEX WI
53089-3875
US

IV. Provider business mailing address

N55W21268 LOGAN DR
MENOMONEE FALLS WI
53051-6211
US

V. Phone/Fax

Practice location:
  • Phone: 262-225-1163
  • Fax:
Mailing address:
  • Phone: 262-225-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number159473
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9919
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: