Healthcare Provider Details

I. General information

NPI: 1003789488
Provider Name (Legal Business Name): MRS. CARLY ANN PORTINCASA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 02/08/2026
Certification Date: 02/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 QUAIL RUN
PINEHURST NC
28374-9096
US

IV. Provider business mailing address

120 QUAIL RUN
PINEHURST NC
28374-9096
US

V. Phone/Fax

Practice location:
  • Phone: 727-743-8873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5023932
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: