MEDICARE: MRS. CARLY K REID FNP-S

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	363LF0000X	Family Nurse Practitioner	6600043-3102	UT

General Provider Information

NPI Number	:	1356097687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLY K REID FNP-S

Provider Business Mailing Address
First Line	:	517 D ST
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84103-2831
Country	:	US
Telephone Number	:	954-923-7440
Fax Number	:

Provider Business Practice Location Address
First Line	:	517 D ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-2831
Country	:	US
Telephone Number	:	954-923-7440
Fax Number	:

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

Provider Enumeration Date	:	02/24/2022
Last Update Date	:	02/22/2023

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