Provider Demographics
NPI:1760464903
Name:EVANGELISTI, JEAN K (APRN)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:K
Last Name:EVANGELISTI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 LITCHFIELD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6268
Mailing Address - Country:US
Mailing Address - Phone:860-489-1984
Mailing Address - Fax:860-496-2195
Practice Address - Street 1:780 LITCHFIELD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6268
Practice Address - Country:US
Practice Address - Phone:860-489-1984
Practice Address - Fax:860-496-2195
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002284363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE400002284CT01OtherANTHEM- INSURANCE
CT705146OtherCONNECTICARE - INSURANCE
CT004234481Medicaid
P06716Medicare UPIN
CTD400008718Medicare PIN