=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962265793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLY JANE WASSERBACH APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2024
-----------------------------------------------------
Last Update Date | 02/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2862 ARDON LN
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-249-3543
-----------------------------------------------------
Fax | 904-748-2569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2862 ARDON LN
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-249-3543
-----------------------------------------------------
Fax | 904-748-2569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 53202
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------