MEDICARE: EBONY NELLON RN

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	4703125193	MI

General Provider Information

NPI Number	:	1982357596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY NELLON RN

Provider Business Mailing Address
First Line	:	2669 MLK JR BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-2562
Country	:	US
Telephone Number	:	313-687-3908
Fax Number	:

Provider Business Practice Location Address
First Line	:	2669 MLK JR BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-2562
Country	:	US
Telephone Number	:	313-687-3908
Fax Number	:

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

Provider Enumeration Date	:	02/02/2022
Last Update Date	:	02/02/2022

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