Provider Demographics
NPI:1669108890
Name:EVANS, HEATHER (PHD, PMHNP-BC, RN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD, PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-963-7917
Mailing Address - Fax:
Practice Address - Street 1:202 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1833
Practice Address - Country:US
Practice Address - Phone:860-963-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT19068163363LP0808X
CT10773363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health