Healthcare Provider Details

I. General information

NPI: 1871910406
Provider Name (Legal Business Name): CARLI A CARNISH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HEISLEY RD
MENTOR OH
44060-1743
US

IV. Provider business mailing address

9485 MENTOR AVE 210
MENTOR OH
44060-8723
US

V. Phone/Fax

Practice location:
  • Phone: 440-392-9550
  • Fax:
Mailing address:
  • Phone: 440-205-5835
  • Fax: 440-205-5744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.15729-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: