1639156904 NPI number — MRS. CHARLOTTE J EVANS FNP

Table of content: MRS. CHARLOTTE J EVANS FNP (NPI 1639156904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639156904 NPI number — MRS. CHARLOTTE J EVANS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
CHARLOTTE
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CUMMINS
Provider Other First Name:
CHARLOTTS
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639156904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6211 WATERFORD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47715-2869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-465-6202
Provider Business Mailing Address Fax Number:
812-465-3621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6211 WATERFORD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47715-2869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-465-6202
Provider Business Practice Location Address Fax Number:
812-465-3621
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71000408A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200171930 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000343511 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 04367929410 . This is a "DONLEY & CO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7483165 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00179584 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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