Provider Demographics
NPI:1477834760
Name:EVANS, KENYA RACQUEL (QMHS, STNA)
Entity Type:Individual
Prefix:MS
First Name:KENYA
Middle Name:RACQUEL
Last Name:EVANS
Suffix:
Gender:F
Credentials:QMHS, STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:LAKEMORE
Mailing Address - State:OH
Mailing Address - Zip Code:44250-0818
Mailing Address - Country:US
Mailing Address - Phone:330-805-5568
Mailing Address - Fax:
Practice Address - Street 1:1266 MAIN ST # 818
Practice Address - Street 2:
Practice Address - City:LAKEMORE
Practice Address - State:OH
Practice Address - Zip Code:44250-9801
Practice Address - Country:US
Practice Address - Phone:330-805-5568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X, 106S00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid