Provider Demographics
NPI:1396216800
Name:PRAVONG, CARLY BROOKE (FNP-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:BROOKE
Last Name:PRAVONG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 W TWAIN DR
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-2327
Mailing Address - Country:US
Mailing Address - Phone:623-399-0119
Mailing Address - Fax:
Practice Address - Street 1:10900 N SCOTTSDALE RD STE 606
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5252
Practice Address - Country:US
Practice Address - Phone:480-368-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ219032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily