1124456736 NPI number — CARLY NEWTON FNP-C

Table of content: CARLY NEWTON FNP-C (NPI 1124456736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124456736 NPI number — CARLY NEWTON FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEWTON
Provider First Name:
CARLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAGNON
Provider Other First Name:
CARLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124456736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3785 WATERLOO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62298-4409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-409-9900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14805 NORTH OUTER 40 RD STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017-6060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-536-0183
Provider Business Practice Location Address Fax Number:
636-536-0526
Provider Enumeration Date:
10/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  2014001970 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 209019723 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2014001970 . This is a "ADULT NURSE PRACTITIONER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 041404932 . This is a "ILLINOIS STATE LICENSE FOR RN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2010022356 . This is a "MISSOURI STATE LICENSE FOR RN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 209019723 . This is a "ADULT/FAMILY NURSE PRACTITIONER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2019010533 . This is a "FAMILY NURSE PRACTITIONER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com