Healthcare Provider Details

I. General information

NPI: 1376621615
Provider Name (Legal Business Name): KATHRYN A PROULX CNP, PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 MAIN ST
SPRINGFIELD MA
01103-2114
US

IV. Provider business mailing address

1049 MAIN ST
SPRINGFIELD MA
01103-2114
US

V. Phone/Fax

Practice location:
  • Phone: 413-739-1100
  • Fax: 413-304-4666
Mailing address:
  • Phone: 413-739-1100
  • Fax: 413-304-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number127180
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number001162
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: