Provider Demographics
NPI:1629666466
Name:EVANS, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
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 1:404 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:BURKEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23922-3130
Mailing Address - Country:US
Mailing Address - Phone:804-514-3429
Mailing Address - Fax:
Practice Address - Street 1:27728 PRINCE EDWARD HWY
Practice Address - Street 2:
Practice Address - City:RICE
Practice Address - State:VA
Practice Address - Zip Code:23966-2702
Practice Address - Country:US
Practice Address - Phone:804-514-3429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider