Provider Demographics
NPI:1568789253
Name:EVAN, UREKA BURNETT
Entity Type:Individual
Prefix:MRS
First Name:UREKA
Middle Name:BURNETT
Last Name:EVAN
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 1:6126 KATHERINE RD
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-1119
Mailing Address - Country:US
Mailing Address - Phone:404-444-4684
Mailing Address - Fax:678-565-1454
Practice Address - Street 1:667 FAIRBURN RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-1423
Practice Address - Country:US
Practice Address - Phone:404-444-4684
Practice Address - Fax:678-565-1454
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASSC00402009-0076174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist