Provider Demographics
NPI:1205392149
Name:EVANS, NATASHA
Entity Type:Individual
Prefix:
First Name:NATASHA
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 1:414 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3347
Mailing Address - Country:US
Mailing Address - Phone:904-945-2357
Mailing Address - Fax:
Practice Address - Street 1:414 11TH ST S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3347
Practice Address - Country:US
Practice Address - Phone:904-945-2357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility