Provider Demographics
NPI:1740663939
Name:NOLA, CARLY JO
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JO
Last Name:NOLA
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 1:11350 MCCORMICK ROAD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:1420 SPRING HILL RD STE 210
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3006
Practice Address - Country:US
Practice Address - Phone:703-738-4342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004998363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical