Healthcare Provider Details

I. General information

NPI: 1235967522
Provider Name (Legal Business Name): NICKESHIA EVANS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 WILLIS AVE STE 57
MINEOLA NY
11501-4406
US

IV. Provider business mailing address

34 WILLIS AVE STE 57
MINEOLA NY
11501-4406
US

V. Phone/Fax

Practice location:
  • Phone: 516-276-1051
  • Fax: 516-276-1051
Mailing address:
  • Phone: 516-276-1051
  • Fax: 516-276-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405946
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: