Provider Demographics
NPI:1598491698
Name:EVANS, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
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 1:482 GREASY CRK
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-8479
Mailing Address - Country:US
Mailing Address - Phone:606-776-0326
Mailing Address - Fax:
Practice Address - Street 1:482 GREASY CRK
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164-8479
Practice Address - Country:US
Practice Address - Phone:606-776-0326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1764124Q00000X
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist