Provider Demographics
NPI:1073223160
Name:EVANS ROGERS, TYLASHEA
Entity Type:Individual
Prefix:
First Name:TYLASHEA
Middle Name:
Last Name:EVANS ROGERS
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 1:811 E ROSEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5109
Mailing Address - Country:US
Mailing Address - Phone:352-702-2252
Mailing Address - Fax:
Practice Address - Street 1:811 E ROSEWOOD LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5109
Practice Address - Country:US
Practice Address - Phone:352-702-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104959200Medicaid