Provider Demographics
NPI:1710092069
Name:COE, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:COE
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 1:1812 MALDEN DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3128
Mailing Address - Country:US
Mailing Address - Phone:843-968-8333
Mailing Address - Fax:
Practice Address - Street 1:1812 MALDEN DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3128
Practice Address - Country:US
Practice Address - Phone:843-968-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00906554OtherMEDICARE RAILROAD PTAN
SCNP1759Medicaid
SCAA05301849Medicare PIN
SCNP1759Medicaid
SCAA05304784Medicare PIN
SCAA05301850Medicare PIN