Ebony T Sallis, LPN

Primary specialty

Licensed Practical NurseTaxonomy code 164W00000X

License

LPN092214 Issued in GA

Practice address

3921 W Baseline Rd
Laveen, AZ 85339-1801

Phone

(623) 606-7532

NPI assigned

Jan 27, 2025

Last updated

Jan 27, 2025By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1737936000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1737936000000",
    "number": "1407669344",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "250 APPLEWOOD DR UNIT 3004",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300466409",
            "telephone_number": "623-606-7532"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3921 W BASELINE RD",
            "city": "LAVEEN",
            "state": "AZ",
            "postal_code": "853391801",
            "telephone_number": "623-606-7532"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SALLIS",
        "first_name": "EBONY",
        "middle_name": "T",
        "credential": "LPN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2025-01-27",
        "last_updated": "2025-01-27",
        "certification_date": "2025-01-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "164W00000X",
            "taxonomy_group": "",
            "desc": "Licensed Practical Nurse",
            "state": "GA",
            "license": "LPN092214",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Licensed Practical Nurse in Laveen, AZ
• Providers in Laveen, AZ by specialty
• Licensed Practical Nurse in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.