Provider Demographics
NPI:1043238207
Name:EVANICH, ELIZABETH ANN (BSN, ANP)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:EVANICH
Suffix:
Gender:F
Credentials:BSN, ANP
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:EVANICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSN
Mailing Address - Street 1:1138 W VERMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013
Mailing Address - Country:US
Mailing Address - Phone:602-626-7207
Mailing Address - Fax:602-222-6562
Practice Address - Street 1:650 EAST INDIAN SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:602-222-6567
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN050197163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology