Provider Demographics
NPI:1073156154
Name:BURNETT, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:BURNETT
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 1:1119 NOGALES BEND DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-6129
Mailing Address - Country:US
Mailing Address - Phone:713-677-1500
Mailing Address - Fax:
Practice Address - Street 1:1119 NOGALES BEND DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-6129
Practice Address - Country:US
Practice Address - Phone:713-677-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27629320OtherDRIVERS LICENSE
TX1073156154Medicaid