Provider Demographics
NPI:1962265793
Name:WASSERBACH, CARLY JANE (APRN)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:JANE
Last Name:WASSERBACH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2862 ARDON LN
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3900
Mailing Address - Country:US
Mailing Address - Phone:307-249-3543
Mailing Address - Fax:904-748-2569
Practice Address - Street 1:2862 ARDON LN
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3900
Practice Address - Country:US
Practice Address - Phone:307-249-3543
Practice Address - Fax:904-748-2569
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY53202363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health