Provider Demographics
NPI:1831732593
Name:EVANS, TEKETRA (LPN, COSMETOLOGIST)
Entity type:Individual
Prefix:
First Name:TEKETRA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPN, COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WALTER PAYTON DR # 222
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3738
Mailing Address - Country:US
Mailing Address - Phone:601-228-1301
Mailing Address - Fax:
Practice Address - Street 1:39 E ZION RD
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-5000
Practice Address - Country:US
Practice Address - Phone:601-606-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies