Provider Demographics
NPI:1659444867
Name:AVERETT, ROSALYN S (RN)
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:S
Last Name:AVERETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 E 100 N
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-1710
Mailing Address - Country:US
Mailing Address - Phone:801-489-9126
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE # 1900
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7033
Practice Address - Fax:801-343-8724
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187512-3102163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT55102OtherPEHP PROVIDER #
UTPR00489Medicaid
UTQM0000039389OtherALTIUS PROVIDER #
UT73-00012OtherUNITED HEALTH CARE ID#
UT103003506102OtherSELECT HEALTH PROVIDER #
UT998877660009Medicaid