Provider Demographics
NPI:1447704135
Name:EVANGELISTA, IREEN
Entity type:Individual
Prefix:
First Name:IREEN
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 W ROOSEVELT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-2564
Mailing Address - Country:US
Mailing Address - Phone:708-632-5600
Mailing Address - Fax:708-632-5602
Practice Address - Street 1:10330 W ROOSEVELT RD STE 200
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2564
Practice Address - Country:US
Practice Address - Phone:708-632-5600
Practice Address - Fax:708-632-5602
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013596363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner