MEDICARE: LIZETTE MANYI EBOT PMHNP-BC

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	1034060	TX

General Provider Information

NPI Number	:	1508448739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZETTE MANYI EBOT PMHNP-BC

Provider Business Mailing Address
First Line	:	4810 HEISMAN DR
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76310-2838
Country	:	US
Telephone Number	:	940-235-6491
Fax Number	:	940-386-9677

Provider Business Practice Location Address
First Line	:	4810 HEISMAN DR
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76310-2838
Country	:	US
Telephone Number	:	940-235-6491
Fax Number	:	940-386-9677

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

Provider Enumeration Date	:	04/27/2021
Last Update Date	:	02/20/2026

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