Provider Demographics
NPI:1093288599
Name:EVANS, TONJA RENEE
Entity Type:Individual
Prefix:
First Name:TONJA
Middle Name:RENEE
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:99 HILL HAVEN RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:GA
Practice Address - Zip Code:30222-3107
Practice Address - Country:US
Practice Address - Phone:706-672-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist