Provider Demographics
NPI:1720760010
Name:EVANGELISTA, MARY JANE (PHD,DNP,PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:PHD,DNP,PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 N PINE GROVE AVE APT 414
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-6641
Mailing Address - Country:US
Mailing Address - Phone:131-291-2344
Mailing Address - Fax:
Practice Address - Street 1:3900 N PINE GROVE AVE APT 414
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-6641
Practice Address - Country:US
Practice Address - Phone:131-291-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.027735363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care