MEDICARE: MRS. JESSICA L EVANS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	53-75168-072	KS

General Provider Information

NPI Number	:	1487969192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA L EVANS NP

Provider Business Mailing Address
First Line	:	1525 MADISON ST STE 2
Second Line	:
City	:	FREDONIA
State	:	KS
Zip	:	66736-1704
Country	:	US
Telephone Number	:	620-378-2068
Fax Number	:	620-378-2312

Provider Business Practice Location Address
First Line	:	1525 MADISON ST STE 2
Second Line	:
City	:	FREDONIA
State	:	KS
Zip	:	66736-1704
Country	:	US
Telephone Number	:	620-378-2068
Fax Number	:	620-378-2312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	08/18/2010

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