Provider Demographics
NPI:1669805578
Name:EVERSOLE, MARY E (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:EVERSOLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-983-3492
Mailing Address - Fax:765-983-7958
Practice Address - Street 1:1100 REID PKWY STE 210
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-962-1337
Practice Address - Fax:765-966-0858
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17256-NP363LF0000X
IN71004556A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000873886OtherANTHEM
OH0102806Medicaid
IN201219820Medicaid
OH0102806Medicaid