Healthcare Provider Details

I. General information

NPI: 1477286789
Provider Name (Legal Business Name): KELLEY NGUYEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 MAIN ST 3RD FL, SUITE C&D
SPRINGFIELD MA
01107-1112
US

IV. Provider business mailing address

280 CHESTNUT ST FL 2
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-5600
  • Fax: 413-794-7297
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA102134
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: