Provider Demographics
NPI:1184272759
Name:EVANGELISTA, EDIL (MSN RN PHN FNPC CCRN)
Entity type:Individual
Prefix:
First Name:EDIL
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:MSN RN PHN FNPC CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27649 PEPPERGRASS CT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-2806
Mailing Address - Country:US
Mailing Address - Phone:714-345-7739
Mailing Address - Fax:
Practice Address - Street 1:425 DIAMOND DR STE 105
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4495
Practice Address - Country:US
Practice Address - Phone:951-674-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily