Provider Demographics
NPI:1083149140
Name:EVANSON, AUDREY (LMT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:EVANSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14061 62 1/2 ST SE
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-9421
Mailing Address - Country:US
Mailing Address - Phone:701-680-9167
Mailing Address - Fax:
Practice Address - Street 1:416 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4142
Practice Address - Country:US
Practice Address - Phone:701-680-9167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1729225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist