Provider Demographics
NPI:1154910149
Name:PUERTOS, EBONIE (RN)
Entity type:Individual
Prefix:
First Name:EBONIE
Middle Name:
Last Name:PUERTOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 SOUTHBREEZE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4864
Practice Address - Country:US
Practice Address - Phone:813-977-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9501623163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse