Provider Demographics
NPI:1275164139
Name:EVANGELISTA, MARIA LOURDES (CRNP-FAMILY)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LOURDES
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:CRNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5728 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1143
Mailing Address - Country:US
Mailing Address - Phone:410-256-0373
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 18
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2132
Practice Address - Country:US
Practice Address - Phone:855-527-7246
Practice Address - Fax:866-229-5063
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR172336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0804Medicaid