Provider Demographics
NPI:1518146372
Name:EVANS, MARIVILLA (LD)
Entity Type:Individual
Prefix:PROF
First Name:MARIVILLA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 67TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-5613
Mailing Address - Country:US
Mailing Address - Phone:727-866-3739
Mailing Address - Fax:727-867-5383
Practice Address - Street 1:2400 67TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-5613
Practice Address - Country:US
Practice Address - Phone:727-866-3739
Practice Address - Fax:727-867-5383
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1270133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist