Provider Demographics
NPI:1275704587
Name:EVANGELISTA, JOSEPHINE ARCILLA (ARNP)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:ARCILLA
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:MARGIE
Other - Last Name:LIZASO ARCILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:2020 SANTA MONICA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2131
Practice Address - Country:US
Practice Address - Phone:310-826-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60338171163W00000X, 363L00000X
CANP 15984363L00000X
WAAP60338791363L00000X
CA15984363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA511361OtherREGISTERED NURSE LICENSE
CA15984OtherNURSE PRACTITIONER LICENS