Provider Demographics
NPI:1164661807
Name:EVANS, WILLIE JAMES (LPN)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:JAMES
Last Name:EVANS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2383 2ND AVENUE
Mailing Address - Street 2:#2304
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10035
Mailing Address - Country:US
Mailing Address - Phone:917-569-3028
Mailing Address - Fax:
Practice Address - Street 1:140 BAY 29
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-5006
Practice Address - Country:US
Practice Address - Phone:718-373-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242506164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse