Provider Demographics
NPI:1376140939
Name:EVANS, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
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 1:300 YUKON DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-6094
Mailing Address - Country:US
Mailing Address - Phone:864-344-6221
Mailing Address - Fax:
Practice Address - Street 1:2320 E NORTH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1247
Practice Address - Country:US
Practice Address - Phone:864-344-6221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-12672278G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC85-0958583OtherHOME CARE