Healthcare Provider Details

I. General information

NPI: 1790450609
Provider Name (Legal Business Name): DIAMOND EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 AIRPORT BLVD STE B
PENSACOLA FL
32504-8622
US

IV. Provider business mailing address

8237 VICELA DRIVE
SARASOTA FL
34249-4549
US

V. Phone/Fax

Practice location:
  • Phone: 850-281-1679
  • Fax:
Mailing address:
  • Phone: 800-210-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: