Provider Demographics
NPI:1083323356
Name:EVANS, DESIREE DAWN
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:DAWN
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 1:2673 DAVISSON RUN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-6838
Mailing Address - Country:US
Mailing Address - Phone:681-342-3200
Mailing Address - Fax:
Practice Address - Street 1:2673 DAVISSON RUN RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-6838
Practice Address - Country:US
Practice Address - Phone:681-342-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34592164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse