=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114752524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARYN CHANEL MASUTOMI APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2024
-----------------------------------------------------
Last Update Date | 09/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9480 DOUBLE DIAMOND PKWY
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89521-5845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-786-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9480 DOUBLE DIAMOND PKWY
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89521-5845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-786-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 882463
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------