Provider Demographics
NPI:1477153229
Name:FEUTZ, EVALENEE MARIE
Entity Type:Individual
Prefix:
First Name:EVALENEE
Middle Name:MARIE
Last Name:FEUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EVALENEE
Other - Middle Name:
Other - Last Name:CLYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8976 CYPRESS PRESERVE PL
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-0830
Mailing Address - Country:US
Mailing Address - Phone:920-285-3698
Mailing Address - Fax:
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA641367H00000X
390200000X
FLAA461367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program