Basic Information
| Provider Information | |||||||||
| NPI: | 1134719537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7721 WEAVER AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631431107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189460117 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 903 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186399255 | ||||||||
| FaxNumber: | 6186398100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2021 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209025504 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 209025504 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.