Provider Demographics
NPI:1205342136
Name:EVANS, CRISTON B (CDCA)
Entity type:Individual
Prefix:
First Name:CRISTON
Middle Name:B
Last Name:EVANS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 SWAUGER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-8898
Mailing Address - Country:US
Mailing Address - Phone:740-285-9624
Mailing Address - Fax:
Practice Address - Street 1:14532 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690
Practice Address - Country:US
Practice Address - Phone:740-285-9624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169327171M00000X
OH156080164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0269005Medicaid
OHAPP-000124755OtherAPP