Healthcare Provider Details

I. General information

NPI: 1972816106
Provider Name (Legal Business Name): KENYATTA EVANS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AT GRAND BLVD, 3RD FLOOR WEST PAVILLION ROOM 320
ST. LOUIS MO
63110-1571
US

IV. Provider business mailing address

1256 PARMER DR
FLORISSANT MO
63031-1964
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-7133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2010021896
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA123575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: