Provider Demographics
NPI:1952567554
Name:EVELYN, GRETTLE AGNES (NP)
Entity Type:Individual
Prefix:MS
First Name:GRETTLE
Middle Name:AGNES
Last Name:EVELYN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 EDGEMERE AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2716
Mailing Address - Country:US
Mailing Address - Phone:718-327-3205
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6500
Practice Address - Country:US
Practice Address - Phone:212-241-6400
Practice Address - Fax:212-876-4671
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-03
Last Update Date:2008-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302171363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health