Provider Demographics
NPI:1881122166
Name:EVANS, MELISSA (LPN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13417-1409
Mailing Address - Country:US
Mailing Address - Phone:315-272-0999
Mailing Address - Fax:
Practice Address - Street 1:27 SAUQUOIT ST
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:NY
Practice Address - Zip Code:13417-1021
Practice Address - Country:US
Practice Address - Phone:315-272-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324964-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse