Basic Information
| Provider Information | |||||||||
| NPI: | 1871009886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOW | ||||||||
| FirstName: | SAGE | ||||||||
| MiddleName: | KENYON | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENYON | ||||||||
| OtherFirstName: | SAGE | ||||||||
| OtherMiddleName: | COLIN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 125 LIBERTY ST | ||||||||
| Address2: | STE 205 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011031109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132717136 | ||||||||
| FaxNumber: | 4132717137 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137947552 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN2268672 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.