Healthcare Provider Details

I. General information

NPI: 1417603788
Provider Name (Legal Business Name): CARLY ANN CLARE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EDMUNDSON PL STE 306
COUNCIL BLUFFS IA
51503-4620
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-5677
  • Fax:
Mailing address:
  • Phone: 402-354-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA167810
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: