Healthcare Provider Details

I. General information

NPI: 1770012379
Provider Name (Legal Business Name): EVELYN DENISE MOFFETT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EVELYN DENISE DARRISAW

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 02/21/2026
Certification Date: 02/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST STE 102
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-3455
  • Fax: 321-434-3456
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9332088
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9332088
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9332088
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: