Provider Demographics
NPI:1366276263
Name:EVANS, KRISTA NICHOLE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:NICHOLE
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 1:104 BISHOP LN
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5009
Mailing Address - Country:US
Mailing Address - Phone:631-438-2885
Mailing Address - Fax:
Practice Address - Street 1:104 BISHOP LN
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-5009
Practice Address - Country:US
Practice Address - Phone:631-438-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist