Provider Demographics
NPI:1689133159
Name:EVANGELISTA, VEA EUNICE GESTIADA (PT)
Entity Type:Individual
Prefix:MRS
First Name:VEA EUNICE
Middle Name:GESTIADA
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:VEA EUNICE
Other - Middle Name:HERNANDEZ
Other - Last Name:GESTIADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8532 125TH ST
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3311
Mailing Address - Country:US
Mailing Address - Phone:646-639-3411
Mailing Address - Fax:
Practice Address - Street 1:8532 125TH ST
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3311
Practice Address - Country:US
Practice Address - Phone:646-639-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty