Basic Information
| Provider Information | |||||||||
| NPI: | 1275704587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANGELISTA | ||||||||
| FirstName: | JOSEPHINE | ||||||||
| MiddleName: | ARCILLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIZASO ARCILLA | ||||||||
| OtherFirstName: | JOSEPHINE | ||||||||
| OtherMiddleName: | MARGIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 S 43RD ST | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903421 | ||||||||
| FaxNumber: | 4256909422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN60338171 | WA | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN60338171 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | NP 15984 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | AP60338791 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 511361 | 01 | CA | REGISTERED NURSE LICENSE | OTHER | 15984 | 01 | CA | NURSE PRACTITIONER LICENS | OTHER |