Provider Demographics
NPI:1952397952
Name:EVERT, DAWN LESLIE (NP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:LESLIE
Last Name:EVERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:LESLIE
Other - Last Name:CARLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:900 INDIANA AVE STE D
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3767
Mailing Address - Country:US
Mailing Address - Phone:719-924-9021
Mailing Address - Fax:719-924-9166
Practice Address - Street 1:900 INDIANA AVE STE D
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3767
Practice Address - Country:US
Practice Address - Phone:719-924-9021
Practice Address - Fax:719-924-9166
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-25
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4650363LF0000X
CO81123163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87339056Medicaid