Provider Demographics
NPI:1972935211
Name:WILLARD, CARLI (APRN)
Entity Type:Individual
Prefix:
First Name:CARLI
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PALOMBA DR
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3888
Mailing Address - Country:US
Mailing Address - Phone:890-745-1623
Mailing Address - Fax:860-741-3618
Practice Address - Street 1:15 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3888
Practice Address - Country:US
Practice Address - Phone:890-745-1623
Practice Address - Fax:860-741-3618
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily