MEDICARE: CARLY FANCHER MS, RDN, LD/N

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1501X	Sports Dietetics Nutrition Registered Dietitian
2	133V00000X	Registered Dietitian	ND7308	FL

General Provider Information

NPI Number	:	1225643810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY FANCHER MS, RDN, LD/N

Provider Business Mailing Address
First Line	:	2360 MAJESTIC BAY LN APT 406
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-3155
Country	:	US
Telephone Number	:	336-905-5966
Fax Number	:

Provider Business Practice Location Address
First Line	:	4180 N ORION BLVD BLDG 77
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32816-8029
Country	:	US
Telephone Number	:	336-905-5966
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2020
Last Update Date	:	09/10/2020

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