Provider Demographics
NPI:1780234633
Name:HANSON, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:HANSON
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 1:32 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:ME
Mailing Address - Zip Code:04217-3819
Mailing Address - Country:US
Mailing Address - Phone:207-824-2193
Mailing Address - Fax:207-824-0012
Practice Address - Street 1:32 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:ME
Practice Address - Zip Code:04217-3819
Practice Address - Country:US
Practice Address - Phone:207-824-2193
Practice Address - Fax:207-824-0012
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP119196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily