Provider Demographics
NPI:1063594893
Name:EVANS, KATHLEEN KAY (NP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:KAY
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6204
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:SUITE 445
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-364-5210
Practice Address - Fax:517-364-5216
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149925363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000002317OtherPHP PIN #
MI5008763770OtherBCBS INDIVIDUAL PIN
MI0N21590Medicare PIN
MI200000002317OtherPHP PIN #