Provider Demographics
NPI:1063715787
Name:EBAKO, STANISLAUS MBONG (RN)
Entity type:Individual
Prefix:
First Name:STANISLAUS
Middle Name:MBONG
Last Name:EBAKO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 MARK CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1882
Mailing Address - Country:US
Mailing Address - Phone:703-746-3400
Mailing Address - Fax:
Practice Address - Street 1:4850 MARK CENTER DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1882
Practice Address - Country:US
Practice Address - Phone:703-746-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001214658163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse