Provider Demographics
NPI:1093427254
Name:EVANS, MARY ALICE
Entity Type:Individual
Prefix:
First Name:MARY ALICE
Middle Name:
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 1:6719 OAK SHADOW DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6719 OAK SHADOW DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8744
Practice Address - Country:US
Practice Address - Phone:614-565-5903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle