Provider Demographics
NPI:1013280338
Name:EVANS, MONICA T (NP)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:T
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 GLENDA DR
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3564
Mailing Address - Country:US
Mailing Address - Phone:478-718-1638
Mailing Address - Fax:478-953-6727
Practice Address - Street 1:116 S HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3904
Practice Address - Country:US
Practice Address - Phone:478-923-0131
Practice Address - Fax:478-922-6530
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN150100OtherNP LICENSE
GA20120246OtherNP- BOARD NUMBER