Provider Demographics
NPI:1871931832
Name:DE LA GARZA, CARLA LYN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:LYN
Last Name:DE LA GARZA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 PINE ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1158
Mailing Address - Country:US
Mailing Address - Phone:334-293-6825
Mailing Address - Fax:334-293-6826
Practice Address - Street 1:1722 PINE ST STE 204
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1158
Practice Address - Country:US
Practice Address - Phone:334-293-6825
Practice Address - Fax:334-293-6826
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-159638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX361137801Medicaid