Healthcare Provider Details

I. General information

NPI: 1659695047
Provider Name (Legal Business Name): GENI L EVANS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 17TH ST
LEWISTON ID
83501-3652
US

IV. Provider business mailing address

1522 17TH ST
LEWISTON ID
83501-3652
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-8416
  • Fax:
Mailing address:
  • Phone: 208-743-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21422A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: