Healthcare Provider Details

I. General information

NPI: 1871912212
Provider Name (Legal Business Name): AMY EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 BRANCH CT
INDEPENDENCE KY
41051-9072
US

IV. Provider business mailing address

615 BRANCH CT
INDEPENDENCE KY
41051-9072
US

V. Phone/Fax

Practice location:
  • Phone: 859-512-9726
  • Fax:
Mailing address:
  • Phone: 859-512-9726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number222678
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: