Provider Demographics
NPI:1558919738
Name:EVANCEVICH, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:EVANCEVICH
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:PO BOX 322
Mailing Address - Street 2:
Mailing Address - City:BABBITT
Mailing Address - State:MN
Mailing Address - Zip Code:55706-0322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 CYPRESS BLVD
Practice Address - Street 2:
Practice Address - City:BABBITT
Practice Address - State:MN
Practice Address - Zip Code:55706-1238
Practice Address - Country:US
Practice Address - Phone:218-827-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider