Healthcare Provider Details

I. General information

NPI: 1841953593
Provider Name (Legal Business Name): TAMARA MASSENGALE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 W STATE ST
ITHACA NY
14850-5432
US

IV. Provider business mailing address

169 RIVERSIDE DR
BINGHAMTON NY
13905-4246
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number310599
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF310599
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: