=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477164556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN FLETCHER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2020
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 JEROME ST
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-3534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-427-2312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 SINGLEFOOT RD
-----------------------------------------------------
City | CHELMSFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01824-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-427-2312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | RN2344282
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------