=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396020699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVANGELISTA C. ANUGWOM RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2011
-----------------------------------------------------
Last Update Date | 10/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4128 ARBOR CT
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-649-6048
-----------------------------------------------------
Fax | 972-677-7978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4128 ARBOR CT
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-649-6048
-----------------------------------------------------
Fax | 972-677-7978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------