Healthcare Provider Details

I. General information

NPI: 1477693661
Provider Name (Legal Business Name): ANNE M. NUNNELLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 CENTER ST
LUDLOW MA
01056-1461
US

IV. Provider business mailing address

819 WORCESTER ST STE 3
SPRINGFIELD MA
01151-1056
US

V. Phone/Fax

Practice location:
  • Phone: 413-547-0012
  • Fax: 413-547-0034
Mailing address:
  • Phone: 413-543-6820
  • Fax: 413-543-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number487
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: