Provider Demographics
NPI:1841957008
Name:EVANCHO, CHARLOTTE D
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:D
Last Name:EVANCHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-0144
Mailing Address - Country:US
Mailing Address - Phone:216-376-6717
Mailing Address - Fax:
Practice Address - Street 1:144 PARK AVE.
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001
Practice Address - Country:US
Practice Address - Phone:216-376-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2471687374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2471687Medicaid