MEDICARE: KINGSLEY EBORU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	301080	AZ

General Provider Information

NPI Number	:	1336916105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KINGSLEY EBORU

Provider Business Mailing Address
First Line	:	5501 N 19TH AVE STE 425
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2481
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 N 19TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2450
Country	:	US
Telephone Number	:	602-755-8343
Fax Number	:	602-755-8362

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	06/03/2026

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Directions to “ KINGSLEY EBORU ” Practice Location

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