Provider Demographics
NPI:1104394071
Name:JORNLIN, CARLY (PNP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:JORNLIN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 AVENUE A APT 7C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-6573
Mailing Address - Country:US
Mailing Address - Phone:302-740-3327
Mailing Address - Fax:
Practice Address - Street 1:8008 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3802
Practice Address - Country:US
Practice Address - Phone:302-740-3327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382905363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics