Provider Demographics
NPI:1740543693
Name:COLVIN, CARLY J
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:J
Last Name:COLVIN
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 1:1247 BRADFORD AVE
Mailing Address - Street 2:APT. 2B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-6184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1247 BRADFORD AVE
Practice Address - Street 2:APT. 2B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6184
Practice Address - Country:US
Practice Address - Phone:315-406-2671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist