Healthcare Provider Details

I. General information

NPI: 1770861007
Provider Name (Legal Business Name): EMILY KATHRYN STAGG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

IV. Provider business mailing address

98 LANCASTER RD
GLASTONBURY CT
06033-1123
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-3494
  • Fax:
Mailing address:
  • Phone: 203-314-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number03277675
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number092976
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: