=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568789253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. UREKA BURNETT EVAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2010
-----------------------------------------------------
Last Update Date | 04/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 667 FAIRBURN RD NW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-444-4684
-----------------------------------------------------
Fax | 678-565-1454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6126 KATHERINE RD
-----------------------------------------------------
City | REX
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30273-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-444-4684
-----------------------------------------------------
Fax | 678-565-1454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | SSC00402009-0076
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------