Healthcare Provider Details

I. General information

NPI: 1902625189
Provider Name (Legal Business Name): CODY ALAN EVERSOLE MSN-FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 BERRY BROOK CIR
PACE FL
32571-6320
US

IV. Provider business mailing address

5517 BERRY BROOK CIR
PACE FL
32571-6320
US

V. Phone/Fax

Practice location:
  • Phone: 520-236-5279
  • Fax:
Mailing address:
  • Phone: 520-236-5279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11035706
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11035706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: