Healthcare Provider Details

I. General information

NPI: 1598482580
Provider Name (Legal Business Name): TYRONE O'BANNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 LIBERTY ST
SPRINGFIELD MA
01104-3736
US

IV. Provider business mailing address

PO BOX 6768
HOLYOKE MA
01041-6768
US

V. Phone/Fax

Practice location:
  • Phone: 413-301-9355
  • Fax:
Mailing address:
  • Phone: 413-218-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN10003790
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2345699
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: