Provider Demographics
NPI:1104397983
Name:EVANS, CONNIE (LMT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
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 1:511 RINGGOLD RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-3405
Mailing Address - Country:US
Mailing Address - Phone:931-378-0553
Mailing Address - Fax:
Practice Address - Street 1:204 HARNETT CT STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2068
Practice Address - Country:US
Practice Address - Phone:931-378-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11933OtherLICENSED MASSAGE THERAPIST