MEDICARE: MRS. MARY JANE EVANGELISTA PHD,DNP,PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	209.027735	IL

General Provider Information

NPI Number	:	1720760010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY JANE EVANGELISTA PHD,DNP,PMHNP

Provider Business Mailing Address
First Line	:	3900 N PINE GROVE AVE APT 414
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6641
Country	:	US
Telephone Number	:	131-291-2344
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 N PINE GROVE AVE APT 414
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6641
Country	:	US
Telephone Number	:	131-291-2344
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2023
Last Update Date	:	09/26/2023

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