Provider Demographics
NPI:1821833195
Name:EVANS, ALISA LOUISE (LPN)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:LOUISE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:16126 SUSSEX ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3852
Mailing Address - Country:US
Mailing Address - Phone:734-772-8927
Mailing Address - Fax:
Practice Address - Street 1:16126 SUSSEX ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3852
Practice Address - Country:US
Practice Address - Phone:734-772-8927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703127487164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse