Provider Demographics
NPI:1447774542
Name:KISSENTANER, EVELINA L
Entity Type:Individual
Prefix:MISS
First Name:EVELINA
Middle Name:L
Last Name:KISSENTANER
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 1:1601 E LAMAR BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-4465
Mailing Address - Country:US
Mailing Address - Phone:817-400-8839
Mailing Address - Fax:682-321-7112
Practice Address - Street 1:1601 E LAMAR BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4465
Practice Address - Country:US
Practice Address - Phone:936-221-1099
Practice Address - Fax:682-321-7112
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory