Provider Demographics
NPI:1063957355
Name:TANDY, EVELYN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:TANDY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1359
Mailing Address - Country:US
Mailing Address - Phone:502-634-2175
Mailing Address - Fax:
Practice Address - Street 1:1609 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1359
Practice Address - Country:US
Practice Address - Phone:502-634-2175
Practice Address - Fax:502-634-2158
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYAT15122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program