MEDICARE: EBONEE GRESHAM FNP

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	163W00000X	Registered Nurse	121515	HI
2	163W00000X	Registered Nurse	232368	GA
3	163W00000X	Registered Nurse	041577002	IL
4	363LF0000X	Family Nurse Practitioner	NP232368	GA
5	163W00000X	Registered Nurse	202205404	OR
6	163W00000X	Registered Nurse	95291307	CA
7	163W00000X	Registered Nurse	924955	NY

General Provider Information

NPI Number	:	1508279837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONEE GRESHAM FNP

Provider Business Mailing Address
First Line	:	PO BOX 257
Second Line	:
City	:	GRAYSON
State	:	GA
Zip	:	30017-0005
Country	:	US
Telephone Number	:	678-719-5525
Fax Number	:

Provider Business Practice Location Address
First Line	:	4280 MEMORIAL DR STE D
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-1216
Country	:	US
Telephone Number	:	678-719-5525
Fax Number	:

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

Provider Enumeration Date	:	06/04/2014
Last Update Date	:	04/16/2026

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