Provider Demographics
NPI:1629419767
Name:SPETRINO, CARLY ANTOINETTE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:ANTOINETTE
Last Name:SPETRINO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1262
Mailing Address - Country:US
Mailing Address - Phone:315-569-3072
Mailing Address - Fax:
Practice Address - Street 1:7211 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1262
Practice Address - Country:US
Practice Address - Phone:315-569-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27025721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist