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General NPI Number Information
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NPI Number | 1225643810
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Entity Type | Individual
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Provider Name | CARLY FANCHER MS, RDN, LD/N
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Gender | Female
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Dates
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Enumeration Date | 09/10/2020
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 4180 N ORION BLVD BLDG 77
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City | ORLANDO
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State | FL
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Zip | 32816-8029
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Country | US
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Telephone | 336-905-5966
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Fax |
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Provider Business Mailing Address
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Address Line | 2360 MAJESTIC BAY LN APT 406
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City | WINTER SPRINGS
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State | FL
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Zip | 32708-3155
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Country | US
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Telephone | 336-905-5966
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1501X
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Taxonomy Name | Sports Dietetics Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | ND7308
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License Number State | FL
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