Provider Demographics
NPI:1396020699
Name:ANUGWOM, EVANGELISTA C (RN)
Entity Type:Individual
Prefix:MS
First Name:EVANGELISTA
Middle Name:C
Last Name:ANUGWOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:214-649-6048
Mailing Address - Fax:972-677-7978
Practice Address - Street 1:4128 ARBOR CT
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:214-649-6048
Practice Address - Fax:972-677-7978
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities