Provider Demographics
NPI:1326645821
Name:HARRIS, CARLY ELAINE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELAINE
Last Name:HARRIS
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 1:148 LEBANON CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DUNNSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22454-2228
Mailing Address - Country:US
Mailing Address - Phone:804-317-4541
Mailing Address - Fax:
Practice Address - Street 1:4494 NORTH PALMER ROAD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:804-317-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003339363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care