Provider Demographics
NPI:1750839858
Name:EVANS, IRETHA
Entity Type:Individual
Prefix:
First Name:IRETHA
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 1:13245 LEVERNE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-4609
Mailing Address - Country:US
Mailing Address - Phone:313-505-4147
Mailing Address - Fax:
Practice Address - Street 1:13245 LEVERNE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-4609
Practice Address - Country:US
Practice Address - Phone:313-505-4147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other