Healthcare Provider Details

I. General information

NPI: 1003591900
Provider Name (Legal Business Name): ASHLEY MARIE GRAVELINE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY MARIE BRODEUR

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STAFFORD ST
SPRINGFIELD MA
01104-4110
US

IV. Provider business mailing address

2 MEDICAL CENTER DR STE 410
SPRINGFIELD MA
01107-1273
US

V. Phone/Fax

Practice location:
  • Phone: 413-748-7095
  • Fax: 413-732-0225
Mailing address:
  • Phone: 413-748-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2266468
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2266468
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: