Provider Demographics
NPI:1487852539
Name:EVERTS, DEBORAH LEE (LPN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:EVERTS
Suffix:
Gender:F
Credentials:LPN
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 331
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-0331
Mailing Address - Country:US
Mailing Address - Phone:607-591-5775
Mailing Address - Fax:
Practice Address - Street 1:4710 STATE HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:TRUXTON
Practice Address - State:NY
Practice Address - Zip Code:13058
Practice Address - Country:US
Practice Address - Phone:607-591-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166924-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01909228Medicaid