Healthcare Provider Details

I. General information

NPI: 1013594092
Provider Name (Legal Business Name): EVITA KVISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 TEAGUE RD STE 500
HANOVER MD
21076-1945
US

IV. Provider business mailing address

225 S LINDER RD APT B301
EAGLE ID
83616-4426
US

V. Phone/Fax

Practice location:
  • Phone: 410-412-3964
  • Fax:
Mailing address:
  • Phone: 208-412-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number65119
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR275992
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: