Healthcare Provider Details

I. General information

NPI: 1164885745
Provider Name (Legal Business Name): ANGEL CUSTODIO HERNANDEZ APN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 08/12/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. PALLIATIVE CARE
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

5218 N KIMBALL AVE APT. 2
CHICAGO IL
60625-4729
US

V. Phone/Fax

Practice location:
  • Phone: 847-503-4222
  • Fax: 847-503-4220
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.013700
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209013700
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: