Provider Demographics
NPI:1891182424
Name:SEQUEIRA, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SEQUEIRA
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 1:1321 NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-2328
Mailing Address - Country:US
Mailing Address - Phone:209-513-1650
Mailing Address - Fax:
Practice Address - Street 1:1321 NORMANDY DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-2328
Practice Address - Country:US
Practice Address - Phone:209-513-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program