Healthcare Provider Details

I. General information

NPI: 1215085238
Provider Name (Legal Business Name): ELLEN MILLER-MACK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WILBRAHAM RD
SPRINGFIELD MA
01109-3161
US

IV. Provider business mailing address

280 CHESTNUT ST 2ND FLOOR
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-3710
  • Fax: 413-794-9595
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN130468
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: