Provider Demographics
NPI:1639516628
Name:EVANS, KERRY BODNAR (AUD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:BODNAR
Last Name:EVANS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ELIZABETH
Other - Last Name:BODNAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2424 DOUBLE CHURCHES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2741
Mailing Address - Country:US
Mailing Address - Phone:706-324-6112
Mailing Address - Fax:706-596-8259
Practice Address - Street 1:2424 DOUBLE CHURCHES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2741
Practice Address - Country:US
Practice Address - Phone:706-324-6112
Practice Address - Fax:706-596-8259
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003929231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135237AMedicaid
AL149113Medicaid
GA202I645319Medicare PIN