Provider Demographics
NPI:1407669344
Name:SALLIS, EBONY T (LPN)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:T
Last Name:SALLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 APPLEWOOD DR UNIT 3004
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-6409
Mailing Address - Country:US
Mailing Address - Phone:623-606-7532
Mailing Address - Fax:
Practice Address - Street 1:3921 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1801
Practice Address - Country:US
Practice Address - Phone:623-606-7532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN092214164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse