Provider Demographics
NPI:1922981216
Name:EVANS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
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 1:292 S FRONTAGE RD # 1036
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2641
Mailing Address - Country:US
Mailing Address - Phone:860-222-5513
Mailing Address - Fax:
Practice Address - Street 1:256 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2054
Practice Address - Country:US
Practice Address - Phone:860-222-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT70376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist