Provider Demographics
NPI:1821776964
Name:EVANGELISTA, REAN (LPN)
Entity Type:Individual
Prefix:
First Name:REAN
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324A S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-4662
Mailing Address - Country:US
Mailing Address - Phone:917-819-9955
Mailing Address - Fax:
Practice Address - Street 1:5034 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330-2022
Practice Address - Country:US
Practice Address - Phone:609-837-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07875100164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse