Provider Demographics
NPI:1760143747
Name:EVANS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EVANS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 SANDERS AVE NE
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-3011
Mailing Address - Country:US
Mailing Address - Phone:256-619-0798
Mailing Address - Fax:720-216-2276
Practice Address - Street 1:9878 W BELLEVIEW AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80123-2101
Practice Address - Country:US
Practice Address - Phone:720-388-8263
Practice Address - Fax:720-216-2276
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-105582363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health