Provider Demographics
NPI:1447022462
Name:THOMAS, CARLY J (CNM)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:J
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:IVERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:339 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1726
Mailing Address - Country:US
Mailing Address - Phone:612-508-0971
Mailing Address - Fax:
Practice Address - Street 1:9333 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2812
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027632363LW0102X
CA236408176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health