Provider Demographics
NPI:1679461982
Name:TITTLE, CARLY RENE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:RENE
Last Name:TITTLE
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 1:28787 N 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-6657
Mailing Address - Country:US
Mailing Address - Phone:925-768-6734
Mailing Address - Fax:
Practice Address - Street 1:17235 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0831
Practice Address - Country:US
Practice Address - Phone:480-878-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program