Basic Information
| Provider Information | |||||||||
| NPI: | 1215984679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 759101 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212750001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032059790 | ||||||||
| FaxNumber: | 9043460113 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 OPITZ BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221913311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036701313 | ||||||||
| FaxNumber: | 9043460113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024166247 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.