Provider Demographics
NPI:1093181422
Name:EVANCZYK, LAUREN (APRN)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:EVANCZYK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:720 2ND AVE STE 102
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1778
Practice Address - Country:US
Practice Address - Phone:502-588-3650
Practice Address - Fax:502-588-7852
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006895A363LF0000X
KY3009656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201336210Medicaid
KY3009656OtherSTATE LICENSE
KY7100391180Medicaid