Provider Demographics
NPI:1962628719
Name:BRONSON, CARLY ANNE (RN, NP)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:ANNE
Last Name:BRONSON
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-1649
Mailing Address - Country:US
Mailing Address - Phone:909-878-8246
Mailing Address - Fax:909-878-8294
Practice Address - Street 1:41820 GARSTIN DR.
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-878-8246
Practice Address - Fax:909-878-8294
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0033221282N00000X
NH060326-23363LF0000X
OHCOA.12102-NP363LF0000X
CA95001879363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1013302Medicaid
OH1013302Medicaid
VT19626228719Medicaid