Provider Demographics
NPI:1821750373
Name:EVANS, ANTONIA (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ANTONIA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ANTONIA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:4155 JEREMY GRV
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8556
Mailing Address - Country:US
Mailing Address - Phone:734-352-7254
Mailing Address - Fax:
Practice Address - Street 1:13880 BRADDOCK RD STE 201
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2461
Practice Address - Country:US
Practice Address - Phone:703-802-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182843363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily