Provider Demographics
NPI:1972260222
Name:WHITLOCK, EBONI CHAMPALE (CPT, CNA)
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:CHAMPALE
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:CPT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BOXWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240
Mailing Address - Country:US
Mailing Address - Phone:270-498-3208
Mailing Address - Fax:
Practice Address - Street 1:131 BOXWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240
Practice Address - Country:US
Practice Address - Phone:270-498-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP9J9G2B9246R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology