Provider Demographics
NPI:1578214672
Name:EVENSON, FOSSY NICOLE
Entity Type:Individual
Prefix:
First Name:FOSSY
Middle Name:NICOLE
Last Name:EVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 E 135TH AVE
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-1965
Mailing Address - Country:US
Mailing Address - Phone:303-997-1242
Mailing Address - Fax:
Practice Address - Street 1:10699 MELODY DR STE 2
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-4131
Practice Address - Country:US
Practice Address - Phone:303-252-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12-276-1010OtherDRIVERS LICENSE