Provider Demographics
NPI:1629314968
Name:EVANS, EMILY IDA (MS, ATC, CMT)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:IDA
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS, ATC, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3113
Mailing Address - Country:US
Mailing Address - Phone:434-544-8649
Mailing Address - Fax:
Practice Address - Street 1:1501 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3113
Practice Address - Country:US
Practice Address - Phone:434-544-8649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260003792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer