Healthcare Provider Details

I. General information

NPI: 1306770417
Provider Name (Legal Business Name): VIANNY DE LA ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIANNY AMADIS

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 PAGE BLVD
SPRINGFIELD MA
01104-3026
US

IV. Provider business mailing address

617 NEWBURY ST
SPRINGFIELD MA
01104-1110
US

V. Phone/Fax

Practice location:
  • Phone: 413-349-5033
  • Fax:
Mailing address:
  • Phone: 413-519-2302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: