Provider Demographics
NPI:1164394557
Name:VRAA, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:VRAA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4931 55TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-3313
Mailing Address - Country:US
Mailing Address - Phone:701-941-2892
Mailing Address - Fax:
Practice Address - Street 1:3333 E BROADWAY AVE STE 1215
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3395
Practice Address - Country:US
Practice Address - Phone:701-941-2892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator