Healthcare Provider Details

I. General information

NPI: 1790592962
Provider Name (Legal Business Name): ALICIA EVANS RD, LD, CSR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 N 5TH ST
LEBANON OR
97355-2875
US

IV. Provider business mailing address

3200 SE MIDVALE DR APT K302
CORVALLIS OR
97333-3168
US

V. Phone/Fax

Practice location:
  • Phone: 541-258-3012
  • Fax: 541-258-3331
Mailing address:
  • Phone: 801-360-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD-D-10194677
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10194677
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: