Provider Demographics
NPI:1275049561
Name:DILLARD, EVANGELA
Entity Type:Individual
Prefix:
First Name:EVANGELA
Middle Name:
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 BRIGHTON BAY BLVD NE APT 7308
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3496
Mailing Address - Country:US
Mailing Address - Phone:727-564-7769
Mailing Address - Fax:727-800-5144
Practice Address - Street 1:10800 BRIGHTON BAY BLVD NE APT 7308
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3496
Practice Address - Country:US
Practice Address - Phone:727-564-7769
Practice Address - Fax:727-800-5144
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17438251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80-0871218Medicaid