Provider Demographics
NPI:1366727596
Name:CONNER, CARLY LITTLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:LITTLE
Last Name:CONNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7963 NORMANDY BLVD
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-6640
Mailing Address - Country:US
Mailing Address - Phone:904-786-0440
Mailing Address - Fax:904-786-0485
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC,
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3927
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106018OtherSTATE OF FLORIDA DEPT. OF HEALTH