Provider Demographics
NPI:1003682832
Name:EVANS, KATHRYN DIANE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DIANE
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18857 E HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-3960
Mailing Address - Country:US
Mailing Address - Phone:479-651-9542
Mailing Address - Fax:
Practice Address - Street 1:18857 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019-3960
Practice Address - Country:US
Practice Address - Phone:479-651-9542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK187179225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist