Healthcare Provider Details

I. General information

NPI: 1659813483
Provider Name (Legal Business Name): EVELINE GWAABE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 N MAIN ST
ENFIELD CT
06082-3372
US

IV. Provider business mailing address

5 N MAIN ST
ENFIELD CT
06082-3372
US

V. Phone/Fax

Practice location:
  • Phone: 860-253-9024
  • Fax: 860-953-9359
Mailing address:
  • Phone: 860-253-9024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10832
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR178804
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10832
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR178804
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: