MEDICARE: MRS. KIM EVANS RN, IBCLC

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	163WL0100X	Lactation Consultant (Registered Nurse)	1-120795	AL

General Provider Information

NPI Number	:	1831819267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM EVANS RN, IBCLC

Provider Business Mailing Address
First Line	:	2758 OLD BIG COVE RD SE
Second Line	:
City	:	OWENS CROSS ROADS
State	:	AL
Zip	:	35763-9762
Country	:	US
Telephone Number	:	985-856-8454
Fax Number	:

Provider Business Practice Location Address
First Line	:	3809 SULLIVAN ST STE 3
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-2366
Country	:	US
Telephone Number	:	256-325-0178
Fax Number	:	256-542-1962

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

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	08/29/2022

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