Provider Demographics
NPI:1760104178
Name:EVANS, MICHELLE WAVERLY (MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:WAVERLY
Last Name:EVANS
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9373 PETER ROY CT
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4265
Mailing Address - Country:US
Mailing Address - Phone:757-319-1228
Mailing Address - Fax:
Practice Address - Street 1:301 MAPLE AVE W STE 120
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4303
Practice Address - Country:US
Practice Address - Phone:703-938-8885
Practice Address - Fax:703-242-2437
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185187207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty