Provider Demographics
NPI:1124107693
Name:EVANS, KELLY (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 CUMBERLAND FALLS HWY
Mailing Address - Street 2:SUITE B201
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2735
Mailing Address - Country:US
Mailing Address - Phone:606-526-9005
Mailing Address - Fax:606-526-8606
Practice Address - Street 1:85 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-8801
Practice Address - Country:US
Practice Address - Phone:606-596-0410
Practice Address - Fax:606-528-8272
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64012206Medicaid
3321160Medicare PIN
KYK113920Medicare PIN
KY0254415Medicare ID - Type Unspecified
KY64012206Medicaid