Provider Demographics
NPI:1063860872
Name:WHOLLEY, CARLY MARIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:MARIE
Last Name:WHOLLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:MARIE
Other - Last Name:VENDITTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 WESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4383
Mailing Address - Country:US
Mailing Address - Phone:860-246-2071
Mailing Address - Fax:
Practice Address - Street 1:1 GARRETT PL
Practice Address - Street 2:APT 4H
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708
Practice Address - Country:US
Practice Address - Phone:860-302-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6181363LF0000X
NYF339574-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily