Provider Demographics
NPI:1396293841
Name:PETERSON, EBONY SHANDREKA (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:SHANDREKA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4904 CAMINO AL NORTE STE 5661
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89033-8801
Mailing Address - Country:US
Mailing Address - Phone:702-350-2032
Mailing Address - Fax:725-262-5536
Practice Address - Street 1:4344 W CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2484
Practice Address - Country:US
Practice Address - Phone:702-350-2032
Practice Address - Fax:725-262-5536
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV821513363L00000X, 363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health