1477153229 NPI number — EVALENEE MARIE FEUTZ

Table of content: EVALENEE MARIE FEUTZ (NPI 1477153229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477153229 NPI number — EVALENEE MARIE FEUTZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEUTZ
Provider First Name:
EVALENEE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLYDE
Provider Other First Name:
EVALENEE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477153229
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8976 CYPRESS PRESERVE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33912-0830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-285-3698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9981 S HEALTHPARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-3618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-343-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/30/2020

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: 367H00000X , with the licence number:  AA641 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367H00000X , with the licence number: AA461 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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