Provider Demographics
NPI:1861173213
Name:MENDOZA, CARLY (FNP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2692 ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-3709
Mailing Address - Country:US
Mailing Address - Phone:631-255-0168
Mailing Address - Fax:
Practice Address - Street 1:4 SPRINGVILLE RD STE B
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-2290
Practice Address - Country:US
Practice Address - Phone:631-283-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily