Provider Demographics
NPI:1306498860
Name:PRUDIC, CARLY PECORIELLO (FNP-BC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:PECORIELLO
Last Name:PRUDIC
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 WOLVERINE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-9653
Mailing Address - Country:US
Mailing Address - Phone:707-649-1509
Mailing Address - Fax:
Practice Address - Street 1:480 WOLVERINE DR STE 3
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-9653
Practice Address - Country:US
Practice Address - Phone:970-764-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-79812163W00000X
COC-APN.0003335-C-NP363L00000X, 363LF0000X
NM568903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000198265Medicaid