Provider Demographics
NPI:1700361672
Name:BEVLY, ELONA DANAIL
Entity Type:Individual
Prefix:
First Name:ELONA
Middle Name:DANAIL
Last Name:BEVLY
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 1:1822 DUNNIDEER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-3004
Mailing Address - Country:US
Mailing Address - Phone:314-817-7043
Mailing Address - Fax:
Practice Address - Street 1:1822 DUNNIDEER DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-3004
Practice Address - Country:US
Practice Address - Phone:314-817-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOM137042022172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver