Healthcare Provider Details

I. General information

NPI: 1396634929
Provider Name (Legal Business Name): CARLY COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3671 BUSINESS DR STE 110
SACRAMENTO CA
95820-2233
US

IV. Provider business mailing address

4850 NATOMAS BLVD APT 1321
SACRAMENTO CA
95835-1293
US

V. Phone/Fax

Practice location:
  • Phone: 916-732-8966
  • Fax:
Mailing address:
  • Phone: 614-290-1057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: