Provider Demographics
NPI:1346025681
Name:GAGNON MELENDEZ, KRISTEN MARIE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:GAGNON MELENDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3779
Mailing Address - Country:US
Mailing Address - Phone:413-426-4837
Mailing Address - Fax:
Practice Address - Street 1:395 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3779
Practice Address - Country:US
Practice Address - Phone:413-426-4837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker