Provider Demographics
NPI:1194332304
Name:PORTER, EBONY G (LPN NURSE)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:G
Last Name:PORTER
Suffix:
Gender:F
Credentials:LPN NURSE
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:G
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN 172408
Mailing Address - Street 1:10324 MOONFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-1105
Mailing Address - Country:US
Mailing Address - Phone:513-370-6303
Mailing Address - Fax:
Practice Address - Street 1:10324 MOONFLOWER CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-1105
Practice Address - Country:US
Practice Address - Phone:513-370-6303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172408164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty