Provider Demographics
NPI:1023689874
Name:COELHO, CARLY ELIZABETH
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:COELHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3281 W TIGER AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93656-9763
Mailing Address - Country:US
Mailing Address - Phone:480-478-5502
Mailing Address - Fax:
Practice Address - Street 1:3281 W TIGER AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:CA
Practice Address - Zip Code:93656-9763
Practice Address - Country:US
Practice Address - Phone:480-478-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95109836163W00000X
CANA95001972367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse