Provider Demographics
NPI:1821860388
Name:EVANGELISTA, BRIANA ROSE
Entity type:Individual
Prefix:
First Name:BRIANA ROSE
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1940
Mailing Address - Country:US
Mailing Address - Phone:409-379-3790
Mailing Address - Fax:
Practice Address - Street 1:9015 MURRAY AVE STE 1000
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3673
Practice Address - Country:US
Practice Address - Phone:408-846-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist