MEDICARE: EBONEE ROSE BLY

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	172A00000X	Driver	VQ610186	OH
2	376J00000X	Homemaker		OH
3	3747P1801X	Personal Care Attendant		OH

General Provider Information

NPI Number	:	1497618730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONEE ROSE BLY

Provider Business Mailing Address
First Line	:	4604 GILMAN RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-6471
Country	:	US
Telephone Number	:	614-371-2645
Fax Number	:

Provider Business Practice Location Address
First Line	:	4604 GILMAN RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-6471
Country	:	US
Telephone Number	:	614-371-2645
Fax Number	:

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

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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Directions to “ EBONEE ROSE BLY ” Practice Location

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