Provider Demographics
NPI:1407239346
Name:ELMER, CARLIE KATE
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:KATE
Last Name:ELMER
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 1:7125 E SUPERSTITION SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9551 SIJAN AVE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-4300
Practice Address - Country:US
Practice Address - Phone:609-540-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14092255A2300X
AK1655282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer