Provider Demographics
NPI:1508001967
Name:FRAGOSO WILKERSON, EVELYN ROVIDA
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:ROVIDA
Last Name:FRAGOSO WILKERSON
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 1:352 ADOBE DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5805
Mailing Address - Country:US
Mailing Address - Phone:707-365-2251
Mailing Address - Fax:
Practice Address - Street 1:352 ADOBE DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-365-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480015BP101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4821OtherDRUG MEDI-CAL