Healthcare Provider Details

I. General information

NPI: 1326178062
Provider Name (Legal Business Name): COMMONWEALTH CLINICAL ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 PLAINFIELD ST
SPRINGFIELD MA
01107-1524
US

IV. Provider business mailing address

380 PLAINFIELD ST
SPRINGFIELD MA
01107-1524
US

V. Phone/Fax

Practice location:
  • Phone: 888-255-4525
  • Fax:
Mailing address:
  • Phone: 888-255-4525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number252442
License Number StateMA

VIII. Authorized Official

Name: MS. LYNN ANN MINNICK
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 18882554525