Provider Demographics
NPI:1083334700
Name:JEFFRIES, GWEN-ELLEN E
Entity Type:Individual
Prefix:
First Name:GWEN-ELLEN
Middle Name:E
Last Name:JEFFRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 KREYSSIG RD
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9619
Mailing Address - Country:US
Mailing Address - Phone:860-983-3059
Mailing Address - Fax:
Practice Address - Street 1:130 SOUTHAMPTON RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-1370
Practice Address - Country:US
Practice Address - Phone:413-568-6600
Practice Address - Fax:413-572-6840
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN96155164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse