Provider Demographics
NPI:1710362678
Name:SPADAFORA, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:SPADAFORA
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 1:167 W BROADWAY
Mailing Address - Street 2:APT 3
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4052
Mailing Address - Country:US
Mailing Address - Phone:516-427-4532
Mailing Address - Fax:
Practice Address - Street 1:167 W BROADWAY
Practice Address - Street 2:APT 3
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4052
Practice Address - Country:US
Practice Address - Phone:516-427-4532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY895790141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY895790141Medicaid
NY895798141Medicaid