Provider Demographics
NPI:1942576764
Name:MARSHALLA, CARLY RENEE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:RENEE
Last Name:MARSHALLA
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 1:563 W MUNCIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-8352
Mailing Address - Country:US
Mailing Address - Phone:559-885-2121
Mailing Address - Fax:
Practice Address - Street 1:1320 E SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7919
Practice Address - Country:US
Practice Address - Phone:559-221-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1286362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry