Provider Demographics
NPI:1659813483
Name:GWAABE, EVELINE
Entity type:Individual
Prefix:
First Name:EVELINE
Middle Name:
Last Name:GWAABE
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 1:4906 WALLINGFORD PL
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:MD
Mailing Address - Zip Code:21755-8423
Mailing Address - Country:US
Mailing Address - Phone:443-367-8686
Mailing Address - Fax:
Practice Address - Street 1:8 DELAY ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6654
Practice Address - Country:US
Practice Address - Phone:203-797-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR178804363LP0808X
CT10832363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily