Provider Demographics
NPI:1164183448
Name:EVANS, DIANE LATONYA
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LATONYA
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 1:9507 HULL STREET RD STE G5
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-1254
Mailing Address - Country:US
Mailing Address - Phone:757-434-4326
Mailing Address - Fax:
Practice Address - Street 1:4301 LAMPLIGHTER CT
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-3427
Practice Address - Country:US
Practice Address - Phone:757-434-4326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332B00000X
VA1201144620332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies