Provider Demographics
NPI:1205422540
Name:EVANS, SHANUN JANIECE
Entity type:Individual
Prefix:
First Name:SHANUN
Middle Name:JANIECE
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 1:12051 MCCLINTOCK CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-4447
Mailing Address - Country:US
Mailing Address - Phone:216-854-1011
Mailing Address - Fax:
Practice Address - Street 1:12051 MCCLINTOCK CT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-4447
Practice Address - Country:US
Practice Address - Phone:216-854-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC1024081744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC102408OtherCOSMETOLOGY