Provider Demographics
NPI:1396012498
Name:MADORE, CARLY MELISSA (APRN)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MELISSA
Last Name:MADORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06438-1259
Mailing Address - Country:US
Mailing Address - Phone:860-714-7420
Mailing Address - Fax:
Practice Address - Street 1:248 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-1264
Practice Address - Country:US
Practice Address - Phone:860-739-5426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4830363LP0200X
CT004830363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400170759OtherMEDICARE- NGS
CT1396012498Medicaid