Provider Demographics
NPI:1508998766
Name:EVANS LACERT, ANGELA R (AUD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:R
Last Name:EVANS LACERT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 6TH AVE S STE 385
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4665
Mailing Address - Country:US
Mailing Address - Phone:727-553-7100
Mailing Address - Fax:727-553-7198
Practice Address - Street 1:625 6TH AVE S STE 385
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4665
Practice Address - Country:US
Practice Address - Phone:727-553-7100
Practice Address - Fax:727-553-7198
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY754231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS00C5OtherFLORIDA BLUE
FLS00C5OtherFLORIDA BLUE
AX621VMedicare PIN
FLAX621WMedicare PIN