Provider Demographics
NPI:1306418173
Name:EVANISH, DENISE ANN
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ANN
Last Name:EVANISH
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 1:22862 INDIAN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-9622
Mailing Address - Country:US
Mailing Address - Phone:216-906-1083
Mailing Address - Fax:
Practice Address - Street 1:22862 INDIAN HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:OH
Practice Address - Zip Code:44090-9622
Practice Address - Country:US
Practice Address - Phone:216-906-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4705951OtherDODD