1508880865 NPI number — MS. KATHLEEN EVANS

Table of content: MS. KATHLEEN EVANS (NPI 1508880865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508880865 NPI number — MS. KATHLEEN EVANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508880865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 BULLDOG BLVD
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-727-2990
Provider Business Mailing Address Fax Number:
321-724-0455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 BULLDOG BLVD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-722-9731
Provider Business Practice Location Address Fax Number:
321-308-0496
Provider Enumeration Date:
07/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133NN1002X , with the licence number:  ND970 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0991-0187 . This is a "NATIONAL CERT BOARD FOR DIABETES EDUCATORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: ND970 . This is a "DIETITIAN/NUTRITIONIST" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".