Healthcare Provider Details

I. General information

NPI: 1215984679
Provider Name (Legal Business Name): GLORIA DENISE EVANS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 OPITZ BLVD
WOODBRIDGE VA
22191-3311
US

IV. Provider business mailing address

PO BOX 759101
BALTIMORE MD
21275-0001
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-1313
  • Fax: 904-346-0113
Mailing address:
  • Phone: 703-205-9790
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024166247
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: