Provider Demographics
NPI:1386022259
Name:TAYLOR, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:TAYLOR
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 1:234 GLENBROOK RD
Mailing Address - Street 2:UNIT 4011
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06269-4011
Mailing Address - Country:US
Mailing Address - Phone:860-486-4700
Mailing Address - Fax:860-486-5300
Practice Address - Street 1:234 GLENBROOK RD
Practice Address - Street 2:UNIT 4011
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06269-4011
Practice Address - Country:US
Practice Address - Phone:860-486-4700
Practice Address - Fax:860-486-5300
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006118363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061496224OtherTAX ID