Provider Demographics
NPI:1093090557
Name:PREMO, CARLY M
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:PREMO
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 1:905 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-1918
Mailing Address - Country:US
Mailing Address - Phone:518-274-6525
Mailing Address - Fax:518-274-6511
Practice Address - Street 1:1 CONWAY CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2108
Practice Address - Country:US
Practice Address - Phone:518-274-6525
Practice Address - Fax:518-274-6511
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY645882163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse