Healthcare Provider Details

I. General information

NPI: 1750423430
Provider Name (Legal Business Name): SANDRA J RAE RNC,WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 MAIN ST SUITE 201
SPRINGFIELD MA
01107-1089
US

IV. Provider business mailing address

85 NONOTUCK ST
HOLYOKE MA
01040-2635
US

V. Phone/Fax

Practice location:
  • Phone: 413-732-1620
  • Fax: 617-616-1617
Mailing address:
  • Phone: 413-732-1620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number268675
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: