Provider Demographics
NPI:1710305016
Name:EVANS, HEATHER LOUISE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LOUISE
Last Name:EVANS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:LOUISE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:258 N RON MCNAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2462
Mailing Address - Country:US
Mailing Address - Phone:843-374-6157
Mailing Address - Fax:
Practice Address - Street 1:258 N RON MCNAIR BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560
Practice Address - Country:US
Practice Address - Phone:843-374-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC211915163WC1500X
SC22622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1710305016Medicaid