Healthcare Provider Details

I. General information

NPI: 1649773268
Provider Name (Legal Business Name): AMY ANN KOWAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

IV. Provider business mailing address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

V. Phone/Fax

Practice location:
  • Phone: 413-747-0705
  • Fax: 413-732-7075
Mailing address:
  • Phone: 413-747-0705
  • Fax: 413-732-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2265800
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2265800
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: