Basic Information
| Provider Information | |||||||||
| NPI: | 1902561756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MINERVA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16300 N PARK DR APT 1501 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489963748 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 34290 FORD RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481853051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344128800 | ||||||||
| FaxNumber: | 3133965353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2021 | ||||||||
| LastUpdateDate: | 11/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 4703080643 | MI | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.