Provider Demographics
NPI:1548564149
Name:EVANGELISTA, KATHLEEN ANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-2248
Mailing Address - Country:US
Mailing Address - Phone:617-846-1982
Mailing Address - Fax:
Practice Address - Street 1:58 ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-2248
Practice Address - Country:US
Practice Address - Phone:617-846-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN213785367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered