Provider Demographics
NPI:1003179888
Name:EVANS, MARY ANN (RN4)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:RN4
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 CORRINE PL
Mailing Address - Street 2:
Mailing Address - City:WASKOM
Mailing Address - State:TX
Mailing Address - Zip Code:75692-5008
Mailing Address - Country:US
Mailing Address - Phone:903-687-3939
Mailing Address - Fax:
Practice Address - Street 1:1035 CRESWELL AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3917
Practice Address - Country:US
Practice Address - Phone:318-676-5286
Practice Address - Fax:318-676-5221
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN066385163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health