Provider Demographics
NPI:1891589784
Name:EVANGELISTA, EMILY GRACE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:EVANGELISTA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 W MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5228
Mailing Address - Country:US
Mailing Address - Phone:813-313-7660
Mailing Address - Fax:
Practice Address - Street 1:3600 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5730
Practice Address - Country:US
Practice Address - Phone:813-313-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program