Provider Demographics
NPI:1417922980
Name:GODWIN, EVELYN W (APRN)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:W
Last Name:GODWIN
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 1:166 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4433
Mailing Address - Country:US
Mailing Address - Phone:860-347-7114
Mailing Address - Fax:
Practice Address - Street 1:4 HAZEL AVE
Practice Address - Street 2:GLENDALE CENTER
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4706
Practice Address - Country:US
Practice Address - Phone:203-723-1456
Practice Address - Fax:203-723-0242
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001411363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004188654Medicaid
CT004188654Medicaid
CT500000658Medicare ID - Type Unspecified