Provider Demographics
NPI:1528359460
Name:WELLS, CARLIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLIANNE
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLI
Other - Middle Name:
Other - Last Name:JORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1610 NE 1ST ST
Mailing Address - Street 2:#4
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3868
Mailing Address - Country:US
Mailing Address - Phone:850-509-2243
Mailing Address - Fax:
Practice Address - Street 1:100 SE 15TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-3908
Practice Address - Country:US
Practice Address - Phone:954-983-1899
Practice Address - Fax:954-986-6846
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant