Healthcare Provider Details

I. General information

NPI: 1316493174
Provider Name (Legal Business Name): MARIA MERCEDES EVANGELISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8044 HARTHAM PARK AVE
RALEIGH NC
27616-9302
US

IV. Provider business mailing address

8044 HARTHAM PARK AVE
RALEIGH NC
27616-9302
US

V. Phone/Fax

Practice location:
  • Phone: 917-669-1433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number258548
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: