=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669534970
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA JANE EBBECKE NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 03/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12675 HESPERIA RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-5878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-241-8063
-----------------------------------------------------
Fax | 760-241-5037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14185 HOPI RD
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-5716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-247-4505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 280926
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------