Provider Demographics
NPI:1760126791
Name:OSBORN, CARLY NICOLE (DC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:NICOLE
Last Name:OSBORN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 BOLTON RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8403
Mailing Address - Country:US
Mailing Address - Phone:419-577-5975
Mailing Address - Fax:
Practice Address - Street 1:225 N CAUSEWAY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5239
Practice Address - Country:US
Practice Address - Phone:386-424-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14026111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor