Provider Demographics
NPI:1235865932
Name:ILAGAN-EVANGELISTA, KAELI JORDAN
Entity Type:Individual
Prefix:
First Name:KAELI
Middle Name:JORDAN
Last Name:ILAGAN-EVANGELISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIKI
Other - Middle Name:JORDAN
Other - Last Name:ILAGAN-EVANGELISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5465 E 2ND ST APT 19
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-3912
Mailing Address - Country:US
Mailing Address - Phone:707-567-7231
Mailing Address - Fax:
Practice Address - Street 1:5465 E 2ND ST APT 19
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-3912
Practice Address - Country:US
Practice Address - Phone:707-567-7231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty