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General NPI Number Information
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NPI Number | 1306498860
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Entity Type | Individual
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Provider Name | CARLY PECORIELLO PRUDIC FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 07/15/2019
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Last Update Date | 07/21/2023
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Provider Practice Location Address
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Address Line | 480 WOLVERINE DR STE 3
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City | BAYFIELD
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State | CO
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Zip | 81122-9653
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Country | US
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Telephone | 970-764-9150
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Fax |
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Provider Business Mailing Address
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Address Line | 480 WOLVERINE DR STE 3
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City | BAYFIELD
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State | CO
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Zip | 81122-9653
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Country | US
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Telephone | 707-649-1509
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN-79812
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | C-APN.0003335-C-NP
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 568903
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License Number State | NM
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | C-APN.0003335-C-NP
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License Number State | CO
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