Provider Demographics
NPI:1962266387
Name:GAECKLE, CAROLYN SIMMONS (PMHNP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SIMMONS
Last Name:GAECKLE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WATERBURY CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05677-0344
Mailing Address - Country:US
Mailing Address - Phone:302-332-6021
Mailing Address - Fax:
Practice Address - Street 1:454 FREEMAN RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663-6230
Practice Address - Country:US
Practice Address - Phone:302-332-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0136910363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health