Provider Demographics
NPI:1790592962
Name:EVANS, ALICIA (RD, LD, CSR)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:RD, LD, CSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SE MIDVALE DR APT K302
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-3168
Mailing Address - Country:US
Mailing Address - Phone:801-360-2671
Mailing Address - Fax:
Practice Address - Street 1:665 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2875
Practice Address - Country:US
Practice Address - Phone:541-258-3012
Practice Address - Fax:541-258-3331
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10194677133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal