Provider Demographics
NPI:1801306170
Name:VALLEJO, EVELYN
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:VALLEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EASTER DR
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-2559
Mailing Address - Country:US
Mailing Address - Phone:956-530-4392
Mailing Address - Fax:956-516-3580
Practice Address - Street 1:200 W INTERSTATE 2 STE D
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3632
Practice Address - Country:US
Practice Address - Phone:956-332-5409
Practice Address - Fax:956-516-3580
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX017898251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX367034101Medicaid