=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174121156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVANGELINE MAHIMA STANDRIDGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2020
-----------------------------------------------------
Last Update Date | 12/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 PARK AVE W
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-2259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-560-5558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1395 EVERGREEN AVE W
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44905-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-314-6211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11009632
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------