Provider Demographics
NPI:1295342731
Name:ANDERSON, EVELYN ANITA
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:ANITA
Last Name:ANDERSON
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 1:202 CHARLIE FULLER RD
Mailing Address - Street 2:
Mailing Address - City:GRANTVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30220-2801
Mailing Address - Country:US
Mailing Address - Phone:770-927-2290
Mailing Address - Fax:404-522-2935
Practice Address - Street 1:202 CHARLIE FULLER RD
Practice Address - Street 2:
Practice Address - City:GRANTVILLE
Practice Address - State:GA
Practice Address - Zip Code:30220-2801
Practice Address - Country:US
Practice Address - Phone:770-927-2290
Practice Address - Fax:404-522-2935
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1133573140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric