Healthcare Provider Details

I. General information

NPI: 1255447645
Provider Name (Legal Business Name): NANCY EAVES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 UNIVERSITY AVE SE
MINNEAPOLIS MN
55414-3325
US

IV. Provider business mailing address

425 BIG BAY BLVD
LUMBERTON MS
39455-5938
US

V. Phone/Fax

Practice location:
  • Phone: 612-767-7222
  • Fax:
Mailing address:
  • Phone: 601-658-2640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number8720
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: