Provider Demographics
NPI:1831819267
Name:EVANS, KIM (RN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2758 OLD BIG COVE RD SE
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-9762
Mailing Address - Country:US
Mailing Address - Phone:985-856-8454
Mailing Address - Fax:
Practice Address - Street 1:3809 SULLIVAN ST STE 3
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2366
Practice Address - Country:US
Practice Address - Phone:256-325-0178
Practice Address - Fax:256-542-1962
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-120795163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant