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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 MAIN RD # 593
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:MA
Mailing Address - Zip Code:01245-9800
Mailing Address - Country:US
Mailing Address - Phone:413-329-8635
Mailing Address - Fax:
Practice Address - Street 1:444 MAIN RD # 593
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:MA
Practice Address - Zip Code:01245-9800
Practice Address - Country:US
Practice Address - Phone:413-329-8635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN256666367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife