Provider Demographics
NPI:1558713990
Name:CARLY, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:CARLY
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 1:5900 ASHWORTH WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0402
Mailing Address - Country:US
Mailing Address - Phone:916-225-2685
Mailing Address - Fax:
Practice Address - Street 1:5900 ASHWORTH WAY
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0402
Practice Address - Country:US
Practice Address - Phone:916-225-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN186694164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse