Provider Demographics
NPI:1245877448
Name:APPLEGATE-ANDERSON, CARLA LUCILE
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:LUCILE
Last Name:APPLEGATE-ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2666 S 2000 E STE 101
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1721
Mailing Address - Country:US
Mailing Address - Phone:801-691-7064
Mailing Address - Fax:
Practice Address - Street 1:2666 SOUTH 2000 EAST
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109
Practice Address - Country:US
Practice Address - Phone:801-691-7064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7044161-4505363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health