Provider Demographics
NPI:1720774151
Name:EVANS, ALTAVIA
Entity type:Individual
Prefix:
First Name:ALTAVIA
Middle Name:
Last Name:EVANS
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 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:3539 LITTLE RD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1811
Practice Address - Country:US
Practice Address - Phone:727-846-9419
Practice Address - Fax:727-816-8707
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11022177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily