Basic Information
| Provider Information | |||||||||
| NPI: | 1639893498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | NIKIYA | ||||||||
| MiddleName: | SHANTA | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AUGUSTA PLANTATION DR UNIT J | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295796440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436852655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104 GEORGE BISHOP PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295797335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2022 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
No ID Information.