Healthcare Provider Details

I. General information

NPI: 1760464903
Provider Name (Legal Business Name): JEAN K EVANGELISTI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 LITCHFIELD ST SUITE 200
TORRINGTON CT
06790-6268
US

IV. Provider business mailing address

780 LITCHFIELD ST SUITE 200
TORRINGTON CT
06790-6268
US

V. Phone/Fax

Practice location:
  • Phone: 860-489-1984
  • Fax: 860-496-2195
Mailing address:
  • Phone: 860-489-1984
  • Fax: 860-496-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number002284
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: