Healthcare Provider Details

I. General information

NPI: 1205575412
Provider Name (Legal Business Name): NICOLE DOMINIQUE EVANS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2022
Last Update Date: 06/04/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20639 KUYKENDAHL RD
SPRING TX
77379-3586
US

IV. Provider business mailing address

20639 KUYKENDAHL RD
SPRING TX
77379-3586
US

V. Phone/Fax

Practice location:
  • Phone: 832-698-0111
  • Fax:
Mailing address:
  • Phone: 832-698-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2168897
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: