Healthcare Provider Details

I. General information

NPI: 1467200212
Provider Name (Legal Business Name): FIONA BLACKBURN EVANS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-3452
  • Fax:
Mailing address:
  • Phone: 508-334-3452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLP06182
License Number StateRI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: