Provider Demographics
NPI:1073949970
Name:RANDO, CARLY ELIZABETH (NP-PSYCHIATRIC - MEN)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:RANDO
Suffix:
Gender:F
Credentials:NP-PSYCHIATRIC - MEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2825
Mailing Address - Country:US
Mailing Address - Phone:508-580-2211
Mailing Address - Fax:508-427-1772
Practice Address - Street 1:529 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2825
Practice Address - Country:US
Practice Address - Phone:508-580-2211
Practice Address - Fax:508-427-1772
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2288512163WP0808X
MARN2288512363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health