Healthcare Provider Details

I. General information

NPI: 1710305016
Provider Name (Legal Business Name): HEATHER LOUISE EVANS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER LOUISE OWENS FNP

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 N RON MCNAIR BLVD
LAKE CITY SC
29560
US

IV. Provider business mailing address

258 N RON MCNAIR BLVD
LAKE CITY SC
29560-2462
US

V. Phone/Fax

Practice location:
  • Phone: 843-374-6157
  • Fax:
Mailing address:
  • Phone: 843-374-6157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number211915
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22622
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: