Provider Demographics
NPI:1235770124
Name:EVANS, KRISTIN ANN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:PROF
Other - First Name:KRISTIANNA
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1732 AVIATION BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2810
Mailing Address - Country:US
Mailing Address - Phone:310-483-5115
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE BLDG A-7
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-284-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94025081390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program