Provider Demographics
NPI:1861020802
Name:EVAN, ELENA MARYANN
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:MARYANN
Last Name:EVAN
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:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:GOODNEWS BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99589-0146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BAY SIDE VIEW 146
Practice Address - Street 2:
Practice Address - City:GOODNEWS BAY
Practice Address - State:AK
Practice Address - Zip Code:99589-0146
Practice Address - Country:US
Practice Address - Phone:907-967-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20-10609-I172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker