Nicolette M Evans, O.D.
Individual provider Active NPI Optometrist · Celina, OH
NPI 1043888035 · NPPES record last updated Jun 16, 2021
Key facts
- NPI
- 1043888035
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- OPT006950 (OH)
- Practice address
- 1025 Grand Lake Rd
Celina, OH 45822-1309 - Phone
- (419) 235-2059
- Fax
- (419) 586-1059
- NPI assigned
- Jun 15, 2021
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OH
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20210805001147 | OH | Practitioner - Optometry | 6204230790 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OPT006950 | OH | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Grand Lake Eyecare LLC | Optometrist | Current |
Accepting new patients |
| Grand Lake Eyecare, LLC | Optometrist | Current |
Accepting new patients |
Locations
1025 Grand Lake Rd
Celina, OH 45822
Phone (419) 586-3151
2024 Holiday Dr
Celina, OH 45822
Phone (419) 586-3151
Interoperability endpoints
- nicollete.evans@direct.revolutionehr.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | OPT006950 | OH | Yes |
Addresses
Primary practice location
1025 Grand Lake Rd
Celina, OH 45822-1309
Mailing address
1025 Grand Lake Rd
Celina, OH 45822-1309
Phone (419) 235-2059
Other providers in Celina, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 16, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.