Healthcare Provider Details

I. General information

NPI: 1346856994
Provider Name (Legal Business Name): EVELYN FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 INDUSTRIAL RD
SPRINGFIELD VA
22151-4206
US

IV. Provider business mailing address

6012 JENNINGS LN
SPRINGFIELD VA
22150-1313
US

V. Phone/Fax

Practice location:
  • Phone: 703-239-6910
  • Fax:
Mailing address:
  • Phone: 540-604-3192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024180174
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001243593
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: