Provider Demographics
NPI:1073912937
Name:EVANS, MICKI JADE
Entity Type:Individual
Prefix:
First Name:MICKI
Middle Name:JADE
Last Name:EVANS
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 1:601 TRENTS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-1117
Mailing Address - Country:US
Mailing Address - Phone:434-544-1500
Mailing Address - Fax:
Practice Address - Street 1:1501 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3113
Practice Address - Country:US
Practice Address - Phone:434-544-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA604324572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer