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General NPI Number Information
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NPI Number | 1417817974
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Entity Type | Individual
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Provider Name | MRS. EBONY BROOKE NICKENS
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Gender | Female
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Dates
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Enumeration Date | 11/17/2025
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Last Update Date | 11/17/2025
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Provider Practice Location Address
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Address Line | 6834 COLEMANS CROSSING AVE STE E
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City | HAYES
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State | VA
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Zip | 23072-3337
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Country | US
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Telephone | 804-677-0223
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Fax | 804-210-1550
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Provider Business Mailing Address
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Address Line | 1619 WINTHROPE DR
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City | NEWPORT NEWS
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State | VA
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Zip | 23602-9638
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Country | US
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Telephone | 804-677-0223
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Fax | 804-210-1550
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | HCO-0001769
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number | HCO-0001769
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License Number State | VA
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