Provider Demographics
NPI:1285330167
Name:HALLER, CARLY LYNN (APRN)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:LYNN
Last Name:HALLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:LYNN
Other - Last Name:LOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3800
Mailing Address - Fax:239-343-3993
Practice Address - Street 1:13685 DOCTORS WAY STE 350
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4347
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11024184363LA2100X
FLAPRN11024184363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117546100Medicaid