Provider Demographics
NPI:1598102766
Name:EVANS, LATAVIA
Entity Type:Individual
Prefix:
First Name:LATAVIA
Middle Name:
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 1:5016 31ST AVE
Mailing Address - Street 2:3A
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1354
Mailing Address - Country:US
Mailing Address - Phone:718-932-6703
Mailing Address - Fax:
Practice Address - Street 1:5016 31ST AVE
Practice Address - Street 2:3A
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1354
Practice Address - Country:US
Practice Address - Phone:718-932-6703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor