Provider Demographics
NPI:1033624218
Name:EVANS, KRISTY JO ELLA (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:JO ELLA
Last Name:EVANS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 SCHOFIELD LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5631
Practice Address - Country:US
Practice Address - Phone:505-609-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-09
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3402224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant