Provider Demographics
NPI:1215379912
Name:MCKILLOP, CARLY J (FNP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:J
Last Name:MCKILLOP
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:J
Other - Last Name:ZOMRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:169 RIVERSIDE DR
Mailing Address - Street 2:LOURDES PRIMARY CARE NETWORK, SUITE 307
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4246
Mailing Address - Country:US
Mailing Address - Phone:607-798-5897
Mailing Address - Fax:607-798-5093
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:LOURDES PRIMARY CARE NETWORK, SUITE 307
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-798-5897
Practice Address - Fax:607-798-5093
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily