Provider Demographics
NPI:1407488521
Name:LARYEA, EVELYN A
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:A
Last Name:LARYEA
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 1:17201 INTERSTATE 45 S
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3311
Mailing Address - Country:US
Mailing Address - Phone:936-270-2227
Mailing Address - Fax:
Practice Address - Street 1:17201 INTERSTATE 45 S
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3311
Practice Address - Country:US
Practice Address - Phone:402-708-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145250363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily