Healthcare Provider Details

I. General information

NPI: 1942279849
Provider Name (Legal Business Name): PHYLLIS ANITA EVANS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JESSE BROWN VA MEDICAL CENTER 820 SOUTH DAMEN AVENUE
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

2736 W 83RD PL
CHICAGO IL
60652-3904
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-7592
  • Fax:
Mailing address:
  • Phone: 773-776-6236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: