Healthcare Provider Details

I. General information

NPI: 1114425386
Provider Name (Legal Business Name): DEAYRIE BONITA EVANS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6228 S 54TH LN
LAVEEN AZ
85339-9639
US

IV. Provider business mailing address

6228 S 54TH LN
LAVEEN AZ
85339-9639
US

V. Phone/Fax

Practice location:
  • Phone: 602-317-7427
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number133069
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP10919
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: