Provider Demographics
NPI:1740244649
Name:SPALLINA, MARY JO (CNM)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:SPALLINA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 CANAL VIEW BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623
Mailing Address - Country:US
Mailing Address - Phone:585-244-3430
Mailing Address - Fax:585-244-2202
Practice Address - Street 1:777 CANAL VIEW BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623
Practice Address - Country:US
Practice Address - Phone:585-244-3430
Practice Address - Fax:585-244-2202
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001001-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02198227Medicaid
NY107179CQOtherPREFERRED CARE
NY1899695OtherGHI
NYP010011001OtherBC/BS
NY000923970001OtherBC/BS OF WESTERN NEW YORK
NY000923970002OtherBC/BS OF WESTERN NEW YORK
NYP010011001OtherBLUE CHOICE