Basic Information
| Provider Information | |||||||||
| NPI: | 1598012189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2049 E 128TH ST | ||||||||
| Address2: | |||||||||
| City: | GRANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493279321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312252829 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1490 E BELTLINE AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495064336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.