Basic Information
| Provider Information | |||||||||
| NPI: | 1568665743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORVILLE | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 44824 BENALD ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935351131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618862902 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | SUIT C | ||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619490131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 05/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 172V00000X | 01 | CA | COMMUNITY HEALTH WORKER | OTHER |