Provider Demographics
NPI:1649728015
Name:EVAN, STEPHANIE MARIE (RN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:EVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10246 HOLDER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2511
Mailing Address - Country:US
Mailing Address - Phone:530-723-4001
Mailing Address - Fax:
Practice Address - Street 1:10246 HOLDER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2511
Practice Address - Country:US
Practice Address - Phone:530-723-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95101898163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse