Provider Demographics
NPI:1619933199
Name:CERIDAN, EVANGELINE (ARNP)
Entity Type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:
Last Name:CERIDAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1703
Mailing Address - Country:US
Mailing Address - Phone:502-629-2500
Mailing Address - Fax:502-629-3166
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1703
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-3166
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3773P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78008919Medicaid
KYS89024Medicare UPIN
KY0547824Medicare ID - Type Unspecified