Provider Demographics
NPI:1609416544
Name:EVANS, REGINA JONELLE (FNP)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:JONELLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 DAHLIA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7347
Mailing Address - Country:US
Mailing Address - Phone:662-207-0806
Mailing Address - Fax:
Practice Address - Street 1:112 W PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773-8710
Practice Address - Country:US
Practice Address - Phone:662-754-3301
Practice Address - Fax:662-754-3304
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily