Provider Demographics
NPI:1629016795
Name:EVANS, KATHY JEAN (NP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JEAN
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-4017
Mailing Address - Country:US
Mailing Address - Phone:662-255-0467
Mailing Address - Fax:662-620-7106
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4017
Practice Address - Country:US
Practice Address - Phone:662-255-0467
Practice Address - Fax:662-620-7106
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR543446363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124239Medicaid
MS00124239Medicaid
MS500000954Medicare PIN