Healthcare Provider Details

I. General information

NPI: 1235865932
Provider Name (Legal Business Name): KAELI JORDAN ILAGAN-EVANGELISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIKI JORDAN ILAGAN-EVANGELISTA

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5465 E 2ND ST APT 19
LONG BEACH CA
90803-3912
US

IV. Provider business mailing address

5465 E 2ND ST APT 19
LONG BEACH CA
90803-3912
US

V. Phone/Fax

Practice location:
  • Phone: 707-567-7231
  • Fax:
Mailing address:
  • Phone: 707-567-7231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: