Provider Demographics
NPI:1790300291
Name:MACKEN, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MACKEN
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 1:23 WASHINGTON PL E
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-1716
Mailing Address - Country:US
Mailing Address - Phone:914-500-5212
Mailing Address - Fax:
Practice Address - Street 1:134 BURKHALL ST APT 105
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-3571
Practice Address - Country:US
Practice Address - Phone:914-500-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2330353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily