Healthcare Provider Details

I. General information

NPI: 1114151214
Provider Name (Legal Business Name): TINA E EVENSON CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA EILEEN KATNIS

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

439009 NORTHSIDE DR
LAKE CITY SD
57247-6149
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-7606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2009001820
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR-130178-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: