Provider Demographics
NPI:1093506313
Name:FRIED, CARLY SAMANTHA (MSN, CPNP-AC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:SAMANTHA
Last Name:FRIED
Suffix:
Gender:F
Credentials:MSN, CPNP-AC
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1200 E RIDGEWOOD AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3937
Mailing Address - Country:US
Mailing Address - Phone:908-616-0871
Mailing Address - Fax:
Practice Address - Street 1:1200 E RIDGEWOOD AVE STE 208
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3937
Practice Address - Country:US
Practice Address - Phone:908-616-0871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF383800-01363LP0200X
NJ26NJ15320100363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics