Healthcare Provider Details

I. General information

NPI: 1033064969
Provider Name (Legal Business Name): ADDIE EBHOMIELEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 WALNUT ST
STOUGHTON MA
02072-4169
US

IV. Provider business mailing address

425 WALNUT ST
STOUGHTON MA
02072-4169
US

V. Phone/Fax

Practice location:
  • Phone: 857-204-2035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2349674
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: