Provider Demographics
NPI:1205575412
Name:EVANS, NICOLE DOMINIQUE (PTA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DOMINIQUE
Last Name:EVANS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20639 KUYKENDAHL RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3586
Mailing Address - Country:US
Mailing Address - Phone:832-698-0111
Mailing Address - Fax:
Practice Address - Street 1:20639 KUYKENDAHL RD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3586
Practice Address - Country:US
Practice Address - Phone:832-698-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2168897208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation