Provider Demographics
NPI:1447740220
Name:DAVIS, CARLY NICOLE (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:NICOLE
Other - Last Name:TRULOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:414 E CAPITOL AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-2478
Mailing Address - Country:US
Mailing Address - Phone:501-590-8950
Mailing Address - Fax:
Practice Address - Street 1:414 E CAPITOL AVE APT 313
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-2478
Practice Address - Country:US
Practice Address - Phone:501-590-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered