Healthcare Provider Details

I. General information

NPI: 1205718483
Provider Name (Legal Business Name): CHARLOTTE WANDELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 NORTH RD
WINDHAM CT
06280
US

IV. Provider business mailing address

PO BOX 94
WINDHAM CT
06280-0094
US

V. Phone/Fax

Practice location:
  • Phone: 860-750-9753
  • Fax: 860-813-6005
Mailing address:
  • Phone: 860-705-9753
  • Fax: 860-813-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15094
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: