Healthcare Provider Details

I. General information

NPI: 1154335354
Provider Name (Legal Business Name): TINA MARIE TKACZEK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA MARIE SCHMUCK NP

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 MAIN STREET
SPRINGFIELD MA
01104
US

IV. Provider business mailing address

2150 MAIN STREET
SPRINGFIELD MA
01104
US

V. Phone/Fax

Practice location:
  • Phone: 413-739-5676
  • Fax: 413-733-5860
Mailing address:
  • Phone: 413-739-5676
  • Fax: 413-733-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number217600
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: