Healthcare Provider Details

I. General information

NPI: 1104780220
Provider Name (Legal Business Name): DESIREE CARPENTER CRPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

73 N MAIN ST
GLOVERSVILLE NY
12078-3044
US

IV. Provider business mailing address

73 N MAIN ST
GLOVERSVILLE NY
12078-3044
US

V. Phone/Fax

Practice location:
  • Phone: 518-725-1512
  • Fax:
Mailing address:
  • Phone: 518-725-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCRPA-6451
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: