Healthcare Provider Details

I. General information

NPI: 1053097733
Provider Name (Legal Business Name): CARMEN RASEAN EVANS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HERITAGE DR STE 230
SOUTHGATE MI
48195-3048
US

IV. Provider business mailing address

41262 SOUTHWIND DR
CANTON MI
48188-3122
US

V. Phone/Fax

Practice location:
  • Phone: 248-832-6700
  • Fax:
Mailing address:
  • Phone: 313-282-8538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704210253
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704210253
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: