Provider Demographics
NPI:1255071882
Name:EVANGELISTA, ELIZABETH BREANNA (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BREANNA
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:BREANNA
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1035 PLACER ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-1170
Mailing Address - Country:US
Mailing Address - Phone:530-246-5710
Mailing Address - Fax:
Practice Address - Street 1:1035 PLACER ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1170
Practice Address - Country:US
Practice Address - Phone:530-246-5951
Practice Address - Fax:530-245-1068
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA198005207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program