Provider Demographics
NPI:1205424314
Name:EVANS, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:OH
Mailing Address - Zip Code:43722-0187
Mailing Address - Country:US
Mailing Address - Phone:740-260-6666
Mailing Address - Fax:
Practice Address - Street 1:11928 MINERAL AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:OH
Practice Address - Zip Code:43722
Practice Address - Country:US
Practice Address - Phone:740-260-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0128529Medicaid