Provider Demographics
NPI:1366615783
Name:STANLEY, CARLY NICOLE (RD, LD, CNSD)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:NICOLE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:RD, LD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 DENISON ST APT B
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6270
Mailing Address - Country:US
Mailing Address - Phone:501-358-1738
Mailing Address - Fax:
Practice Address - Street 1:2 SAINT VINCENT CIR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5423
Practice Address - Country:US
Practice Address - Phone:501-552-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR880133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic