Healthcare Provider Details

I. General information

NPI: 1154408805
Provider Name (Legal Business Name): LYNNE L GAGON APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 E MAIN ST
VERNAL UT
84078-2643
US

IV. Provider business mailing address

PO BOX 516
JENSEN UT
84035-0516
US

V. Phone/Fax

Practice location:
  • Phone: 435-781-5746
  • Fax:
Mailing address:
  • Phone: 435-781-5476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number203926-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number203926-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: