Provider Demographics
NPI:1770861007
Name:STAGG, EMILY KATHRYN (APRN)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KATHRYN
Last Name:STAGG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1123
Mailing Address - Country:US
Mailing Address - Phone:203-314-9339
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-533-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03277675163WA0400X
CT092976163WP0807X
CT4704363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008037446Medicaid
D400063683Medicare PIN
CTCSP.0051127OtherCONTROLLED SUBSTANCE REGISTRATION FOR PRACTICIONER
D400063683Medicare PIN
MS2431168OtherDEA
12320670OtherCAQH