Provider Demographics
NPI:1770012379
Name:MOFFETT, EVELYN DENISE (APRN)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:DENISE
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:DENISE
Other - Last Name:DARRISAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-3455
Practice Address - Fax:321-434-3456
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9332088163WC0200X
FLARNP9332088363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJA626ZOtherFL MEDICARE
FLP02169610OtherFL RR MEDICARE
FL021420000Medicaid