Provider Demographics
NPI:1538494802
Name:DETTERMAN, CARLY A (CNM)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:A
Last Name:DETTERMAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:SUITE 4D
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-8336
Practice Address - Fax:413-794-7345
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MARN256666367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife