Provider Demographics
NPI:1457953135
Name:KNOBLAUCH, CARLY ANNE
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANNE
Last Name:KNOBLAUCH
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 1:13701 W LOST CREEK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-7043
Mailing Address - Country:US
Mailing Address - Phone:316-619-9803
Mailing Address - Fax:
Practice Address - Street 1:10111 E 21ST ST N STE 405
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3581
Practice Address - Country:US
Practice Address - Phone:316-796-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-79808-022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily