Provider Demographics
NPI:1578830956
Name:LOUCKS, CAROL A (APRN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:LOUCKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 W 1170 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2923
Mailing Address - Country:US
Mailing Address - Phone:801-472-6111
Mailing Address - Fax:
Practice Address - Street 1:1629 W 1170 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2923
Practice Address - Country:US
Practice Address - Phone:801-472-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT202205-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily