Provider Demographics
NPI:1881114767
Name:EVANGELISTA, MARY K (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4321 FIR ST
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3049
Mailing Address - Country:US
Mailing Address - Phone:219-392-7224
Mailing Address - Fax:
Practice Address - Street 1:4321 FIR ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3049
Practice Address - Country:US
Practice Address - Phone:219-765-0597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007197A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily