Provider Demographics
NPI:1720546294
Name:NIMMO, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:NIMMO
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 1:2 NICHOLAS CT
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-4616
Mailing Address - Country:US
Mailing Address - Phone:516-993-5440
Mailing Address - Fax:
Practice Address - Street 1:2 NICHOLAS CT
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-4616
Practice Address - Country:US
Practice Address - Phone:516-993-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency