Provider Demographics
NPI:1598012189
Name:EVANS, KRISTEN LEE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEE
Last Name:EVANS
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 1:2049 E 128TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9321
Mailing Address - Country:US
Mailing Address - Phone:231-225-2829
Mailing Address - Fax:
Practice Address - Street 1:1490 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4336
Practice Address - Country:US
Practice Address - Phone:616-940-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker