Provider Demographics
NPI:1700479011
Name:EASLEY, KEVONNA
Entity type:Individual
Prefix:
First Name:KEVONNA
Middle Name:
Last Name:EASLEY
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:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:OAK CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27857-0057
Mailing Address - Country:US
Mailing Address - Phone:252-217-1336
Mailing Address - Fax:
Practice Address - Street 1:311 S WEST AVENUE
Practice Address - Street 2:
Practice Address - City:OAK CITY
Practice Address - State:NC
Practice Address - Zip Code:27857
Practice Address - Country:US
Practice Address - Phone:252-217-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency