Provider Demographics
NPI:1598435091
Name:EVANS, LONNIE RAY (LVN)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:RAY
Last Name:EVANS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4654 E AVENUE S UNIT 243
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93552-4454
Mailing Address - Country:US
Mailing Address - Phone:661-450-5765
Mailing Address - Fax:
Practice Address - Street 1:4654 E AVENUE S UNIT 243
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552-4454
Practice Address - Country:US
Practice Address - Phone:661-450-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA289178164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse