Provider Demographics
NPI:1992286777
Name:O'NEAL, CARLY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:O'NEAL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ENGLEWOOD CV
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-8725
Mailing Address - Country:US
Mailing Address - Phone:662-397-4574
Mailing Address - Fax:
Practice Address - Street 1:2100 E CHAMBERS DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-8938
Practice Address - Country:US
Practice Address - Phone:662-286-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902870363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS902870OtherPMHNP