MEDICARE: LEAH EVANS APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R73494	AR
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	A003320	AR

General Provider Information

NPI Number	:	1043441173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH EVANS APN

Provider Business Mailing Address
First Line	:	455 W CLEBURN ST
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-1916
Country	:	US
Telephone Number	:	501-952-0883
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 W CENTER ST STE 200
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-6073
Country	:	US
Telephone Number	:	501-661-0720
Fax Number	:	501-325-7938

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	07/12/2021

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