Healthcare Provider Details

I. General information

NPI: 1720760010
Provider Name (Legal Business Name): MARY JANE EVANGELISTA PHD,DNP,PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 N PINE GROVE AVE APT 414
CHICAGO IL
60613-6641
US

IV. Provider business mailing address

3900 N PINE GROVE AVE APT 414
CHICAGO IL
60613-6641
US

V. Phone/Fax

Practice location:
  • Phone: 131-291-2344
  • Fax:
Mailing address:
  • Phone: 131-291-2344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.027735
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: