Basic Information
| Provider Information | |||||||||
| NPI: | 1639569247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNCHES | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, FNP-C, AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
| FaxNumber: | 3103926642 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
| FaxNumber: | 3103926642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95002049 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.