Healthcare Provider Details

I. General information

NPI: 1164091963
Provider Name (Legal Business Name): NICOLE CARRETTA PHALEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 01/25/2022
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MAPLE ST STE 1
HOLYOKE MA
01040-5140
US

IV. Provider business mailing address

230 MAPLE ST STE 1
HOLYOKE MA
01040-5140
US

V. Phone/Fax

Practice location:
  • Phone: 413-420-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number163883
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2353271
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2353271
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: