Provider Demographics
NPI:1760513667
Name:EWELL, CAROLYN JEAN (FNP)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:JEAN
Last Name:EWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:JEAN
Other - Last Name:GAGLIASSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:801-442-3168
Mailing Address - Fax:
Practice Address - Street 1:136 N 500 W
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2758
Practice Address - Country:US
Practice Address - Phone:435-722-4843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2235264405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPO9724Medicare UPIN