Healthcare Provider Details

I. General information

NPI: 1720774151
Provider Name (Legal Business Name): ALTAVIA EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 12/15/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3539 LITTLE RD
TRINITY FL
34655-1811
US

IV. Provider business mailing address

5400 PINEHURST DR
SPRING HILL FL
34606-3833
US

V. Phone/Fax

Practice location:
  • Phone: 727-846-9419
  • Fax: 727-816-8707
Mailing address:
  • Phone: 352-277-5348
  • Fax: 352-606-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11022177
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: