Healthcare Provider Details

I. General information

NPI: 1093857542
Provider Name (Legal Business Name): MARY J EVANS CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E LIBERTY ST SUITE 1005
LOUISVILLE KY
40202-1530
US

IV. Provider business mailing address

250 E LIBERTY ST SUITE 1005
LOUISVILLE KY
40202-1530
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-4448
  • Fax: 502-589-1209
Mailing address:
  • Phone: 502-589-4448
  • Fax: 502-589-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number1025933
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number28122666A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: