Provider Demographics
NPI:1841076742
Name:NICOLAU, CARLY JANE
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JANE
Last Name:NICOLAU
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 1:1695 NE PURCELL BLVD APT 16
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6160
Mailing Address - Country:US
Mailing Address - Phone:541-350-0749
Mailing Address - Fax:
Practice Address - Street 1:23 NW GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2078
Practice Address - Country:US
Practice Address - Phone:541-383-4293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-CRM-2333175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist