1184272759 NPI number — EDIL EVANGELISTA MSN RN PHN FNPC CCRN

Table of content: EDIL EVANGELISTA MSN RN PHN FNPC CCRN (NPI 1184272759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184272759 NPI number — EDIL EVANGELISTA MSN RN PHN FNPC CCRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANGELISTA
Provider First Name:
EDIL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN RN PHN FNPC CCRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184272759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27649 PEPPERGRASS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-2806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-345-7739
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 DIAMOND DR STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ELSINORE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92530-4495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-674-8779
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  95012122 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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