Provider Demographics
NPI:1902625189
Name:EVERSOLE, CODY ALAN (MSN-FNP)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:ALAN
Last Name:EVERSOLE
Suffix:
Gender:
Credentials:MSN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5517 BERRY BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-6320
Mailing Address - Country:US
Mailing Address - Phone:520-236-5279
Mailing Address - Fax:
Practice Address - Street 1:5517 BERRY BROOK CIR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-6320
Practice Address - Country:US
Practice Address - Phone:520-236-5279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035706207Q00000X
FLAPRN11035706363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine