Healthcare Provider Details

I. General information

NPI: 1477523777
Provider Name (Legal Business Name): PHYLLIS ANDREA STYSPECK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: PHYLLIS EMERSON-STYSPECK FNP-C

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 CAREW ST EP LAB
SPRINGFIELD MA
01102-9012
US

IV. Provider business mailing address

102 OLD AMHERST RD
SUNDERLAND MA
01375-9558
US

V. Phone/Fax

Practice location:
  • Phone: 413-748-9621
  • Fax: 413-748-9634
Mailing address:
  • Phone: 413-665-8982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number169848
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: