Provider Demographics
NPI:1760871099
Name:WIRICK, CARLY ROSE (RN, APRN, AGACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:ROSE
Last Name:WIRICK
Suffix:
Gender:F
Credentials:RN, APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 LAMAR
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:KS
Mailing Address - Zip Code:66085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16500 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:KS
Practice Address - Zip Code:66085-8763
Practice Address - Country:US
Practice Address - Phone:913-205-5767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76439-101363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner