Healthcare Provider Details

I. General information

NPI: 1962234898
Provider Name (Legal Business Name): CARLY MACE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 E EAU GALLIE BLVD STE A
INDIAN HARBOUR BEACH FL
32937-4874
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-549-0153
  • Fax: 321-434-3682
Mailing address:
  • Phone: 321-549-0153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11034678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: