Provider Demographics
NPI:1306588991
Name:COLEMAN, EVELYN R
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:R
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 DEBRA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7817
Mailing Address - Country:US
Mailing Address - Phone:662-347-5965
Mailing Address - Fax:662-537-7887
Practice Address - Street 1:1662 DEBRA DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7817
Practice Address - Country:US
Practice Address - Phone:662-347-5965
Practice Address - Fax:662-537-7887
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305S00000X
MS305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service