MEDICARE: CARLY RENEE MARSHALLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A128636	CA

General Provider Information

NPI Number	:	1942576764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY RENEE MARSHALLA

Provider Business Mailing Address
First Line	:	563 W MUNCIE AVE
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93619-8352
Country	:	US
Telephone Number	:	559-885-2121
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 E SHAW AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-7919
Country	:	US
Telephone Number	:	559-221-3314
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2012
Last Update Date	:	06/24/2022

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