Basic Information
Provider Information
NPI: 1003014929
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EVANS
FirstName: KRISTINE
MiddleName: MARIE
NamePrefix: MISS
NameSuffix:  
Credential: A.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 63066 MARSH ORCHID DR
Address2:  
City: BEND
State: OR
PostalCode: 977018331
CountryCode: US
TelephoneNumber: 5414208564
FaxNumber:  
Practice Location
Address1: 63360 NW BRITTA ST STE 1
Address2:  
City: BEND
State: OR
PostalCode: 977019475
CountryCode: US
TelephoneNumber: 5413184845
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/03/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  Y Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


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