Healthcare Provider Details

I. General information

NPI: 1790035012
Provider Name (Legal Business Name): TAMARA LEE CONNELLY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMARA LEE SCAGGS APRN

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 SHAKER RD
EAST LONGMEADOW MA
01028-2731
US

IV. Provider business mailing address

2202 MILL POND DR
SOUTH WINDSOR CT
06074
US

V. Phone/Fax

Practice location:
  • Phone: 413-525-3958
  • Fax: 413-525-3943
Mailing address:
  • Phone: 860-394-9792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2285565
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5106
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: