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General NPI Number Information
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NPI Number | 1164885745
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Entity Type | Individual
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Provider Name | ANGEL CUSTODIO HERNANDEZ APN-CNP
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Gender | Male
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Dates
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Enumeration Date | 04/01/2016
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 2650 RIDGE AVE. PALLIATIVE CARE
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City | EVANSTON
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State | IL
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Zip | 60201-1718
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Country | US
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Telephone | 847-503-4222
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Fax | 847-503-4220
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Provider Business Mailing Address
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Address Line | 5218 N KIMBALL AVE APT. 2
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City | CHICAGO
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State | IL
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Zip | 60625-4729
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209.013700
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209013700
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License Number State | IL
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