Provider Demographics
NPI:1013552777
Name:GAYNOR, CARLI R
Entity Type:Individual
Prefix:
First Name:CARLI
Middle Name:R
Last Name:GAYNOR
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 1:242 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18421-1410
Mailing Address - Country:US
Mailing Address - Phone:570-604-2838
Mailing Address - Fax:
Practice Address - Street 1:355 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SIMPSON
Practice Address - State:PA
Practice Address - Zip Code:18407-1213
Practice Address - Country:US
Practice Address - Phone:570-604-2838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3747A0650XMedicaid