Provider Demographics
NPI:1407533607
Name:WHITTED, EBONIE M
Entity type:Individual
Prefix:
First Name:EBONIE
Middle Name:M
Last Name:WHITTED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 SW WILLISTON RD APT 322
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-3968
Mailing Address - Country:US
Mailing Address - Phone:224-520-0630
Mailing Address - Fax:
Practice Address - Street 1:2800 SW WILLISTON RD APT 322
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-3968
Practice Address - Country:US
Practice Address - Phone:224-520-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer