Provider Demographics
NPI:1124456736
Name:NEWTON, CARLY (FNP-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:NEWTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:GAGNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:3785 WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-4409
Mailing Address - Country:US
Mailing Address - Phone:618-409-9900
Mailing Address - Fax:
Practice Address - Street 1:14805 NORTH OUTER 40 RD STE 320
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-6060
Practice Address - Country:US
Practice Address - Phone:636-536-0183
Practice Address - Fax:636-536-0526
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014001970363LA2200X
IL209019723363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014001970OtherADULT NURSE PRACTITIONER
IL041404932OtherILLINOIS STATE LICENSE FOR RN
MO2010022356OtherMISSOURI STATE LICENSE FOR RN
IL209019723OtherADULT/FAMILY NURSE PRACTITIONER
MO2019010533OtherFAMILY NURSE PRACTITIONER