Provider Demographics
NPI:1497156855
Name:EDSTROM, GRETCHEN (RN, CDE)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 PAULA LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1521
Mailing Address - Country:US
Mailing Address - Phone:860-608-0559
Mailing Address - Fax:
Practice Address - Street 1:194 HOWARD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5544
Practice Address - Country:US
Practice Address - Phone:860-444-3366
Practice Address - Fax:860-444-3394
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10.R49980163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator