Provider Demographics
NPI:1104978873
Name:HAMILTON, CARLIE JO (FNP)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:JO
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12272 S 800 E
Mailing Address - Street 2:SUITE A
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9789
Mailing Address - Country:US
Mailing Address - Phone:801-523-1300
Mailing Address - Fax:801-523-1301
Practice Address - Street 1:12272 S 800 E
Practice Address - Street 2:SUITE A
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9789
Practice Address - Country:US
Practice Address - Phone:801-523-1300
Practice Address - Fax:801-523-1301
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT294110-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ51382Medicare UPIN