Healthcare Provider Details

I. General information

NPI: 1093022501
Provider Name (Legal Business Name): MS. EVELYN NADINE WULLNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 ASPEN DR
S GLASTONBURY CT
06073-2938
US

IV. Provider business mailing address

30 ASPEN DR
S GLASTONBURY CT
06073-2938
US

V. Phone/Fax

Practice location:
  • Phone: 925-366-4214
  • Fax:
Mailing address:
  • Phone: 925-366-4214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number004193
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: