Provider Demographics
NPI:1073251104
Name:EVENSON, BETTE ANN
Entity Type:Individual
Prefix:
First Name:BETTE
Middle Name:ANN
Last Name:EVENSON
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:BETTE ANN EVENSON
Mailing Address - Street 2:UNIT 1804
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6989
Mailing Address - Country:US
Mailing Address - Phone:619-838-2203
Mailing Address - Fax:
Practice Address - Street 1:5790 CASA GRANDE WAY
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2109
Practice Address - Country:US
Practice Address - Phone:442-999-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN2435821OtherDRIVER LICENSE