Healthcare Provider Details

I. General information

NPI: 1861109597
Provider Name (Legal Business Name): ELIZABETH ANN AVERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL CENTER DR
SPRINGFIELD MA
01107-1270
US

IV. Provider business mailing address

2 MEDICAL CENTER DR
SPRINGFIELD MA
01107-1270
US

V. Phone/Fax

Practice location:
  • Phone: 413-748-7095
  • Fax:
Mailing address:
  • Phone: 413-748-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2329725
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: