Provider Demographics
NPI:1770291882
Name:MACKER, CARLY (CRNP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MACKER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:BRUNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1714 LATONA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-3028
Mailing Address - Country:US
Mailing Address - Phone:304-794-9568
Mailing Address - Fax:
Practice Address - Street 1:1503 LANSDOWNE AVE STE 3002
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-1308
Practice Address - Country:US
Practice Address - Phone:610-237-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026546363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics