Provider Demographics
NPI:1043836968
Name:EVERNHAM, MARY MYLENE (ADMINISTRATOR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MYLENE
Last Name:EVERNHAM
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 GREYNOLDS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-4221
Mailing Address - Country:US
Mailing Address - Phone:352-556-2947
Mailing Address - Fax:352-556-2947
Practice Address - Street 1:3010 GREYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-4221
Practice Address - Country:US
Practice Address - Phone:352-556-2947
Practice Address - Fax:352-556-2947
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171241113310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility