Basic Information
| Provider Information | |||||||||
| NPI: | 1083334700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFRIES | ||||||||
| FirstName: | GWEN-ELLEN | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 KREYSSIG RD | ||||||||
| Address2: | |||||||||
| City: | BROAD BROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060169619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609833059 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 SOUTHAMPTON RD | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010851370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135686600 | ||||||||
| FaxNumber: | 4135726840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2022 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LN96155 | MA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.