1144925090 NPI number — DR. MYRTLE EVANS DRPH, MSPH, OTR/L

Table of content: DR. MYRTLE EVANS DRPH, MSPH, OTR/L (NPI 1144925090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144925090 NPI number — DR. MYRTLE EVANS DRPH, MSPH, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
MYRTLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DRPH, MSPH, OTR/L
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:
1144925090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12530 FAIRWOOD PKWY STE 102 PMB 1079
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20720-6357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-854-8633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 MERCANTILE LN STE 129-22
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774-5327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-854-8633
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2023

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: 225X00000X , with the licence number:  04664 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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