Provider Demographics
NPI:1083239818
Name:EVANS, AUDRA ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:ELIZABETH
Last Name:EVANS
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 1:3060 DAYTON XENIA RD STE C
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6393
Mailing Address - Country:US
Mailing Address - Phone:937-427-2225
Mailing Address - Fax:937-405-1078
Practice Address - Street 1:3060 DAYTON XENIA RD STE C
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6393
Practice Address - Country:US
Practice Address - Phone:937-427-2225
Practice Address - Fax:937-405-1078
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.020047225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist