Provider Demographics
NPI:1376139097
Name:NDERA, EVELYNE
Entity Type:Individual
Prefix:
First Name:EVELYNE
Middle Name:
Last Name:NDERA
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 1:2506 W DUNLAP AVE APT 338
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2862
Mailing Address - Country:US
Mailing Address - Phone:602-907-2488
Mailing Address - Fax:
Practice Address - Street 1:2506 W DUNLAP AVE APT 338
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2862
Practice Address - Country:US
Practice Address - Phone:602-907-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1234Medicaid