Provider Demographics
NPI:1962198283
Name:EVANS, PETULIA
Entity type:Individual
Prefix:
First Name:PETULIA
Middle Name:
Last Name:EVANS
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 1:9550 S EMERALD AVENUE
Mailing Address - Street 2:STE G
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1026
Mailing Address - Country:US
Mailing Address - Phone:312-662-3664
Mailing Address - Fax:
Practice Address - Street 1:9550 S EMERALD AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1026
Practice Address - Country:US
Practice Address - Phone:312-662-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049163422183700000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No183700000XPharmacy Service ProvidersPharmacy Technician