Healthcare Provider Details

I. General information

NPI: 1760344626
Provider Name (Legal Business Name): CARLE MCNULTY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOLT RD
GLENVILLE NY
12302-6903
US

IV. Provider business mailing address

401 BOLT RD
GLENVILLE NY
12302-6903
US

V. Phone/Fax

Practice location:
  • Phone: 518-495-5577
  • Fax:
Mailing address:
  • Phone: 518-495-5577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004060
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: