Provider Demographics
NPI:1184210122
Name:EVANKO, NICOLE K (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:EVANKO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 PADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7044
Mailing Address - Country:US
Mailing Address - Phone:203-630-5356
Mailing Address - Fax:
Practice Address - Street 1:883 PADDOCK AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7044
Practice Address - Country:US
Practice Address - Phone:203-630-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0054701163W00000X
CT012421363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse