Provider Demographics
NPI:1316217235
Name:EVANS, NICOLE L (LMT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-2440
Mailing Address - Country:US
Mailing Address - Phone:941-484-6503
Mailing Address - Fax:941-484-6506
Practice Address - Street 1:258 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2440
Practice Address - Country:US
Practice Address - Phone:941-484-6503
Practice Address - Fax:941-484-6506
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA64263225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist