Provider Demographics
NPI:1154408805
Name:GAGON, LYNNE L (APRN-BC)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:L
Last Name:GAGON
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:JENSEN
Mailing Address - State:UT
Mailing Address - Zip Code:84035-0516
Mailing Address - Country:US
Mailing Address - Phone:435-781-5476
Mailing Address - Fax:
Practice Address - Street 1:147 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2643
Practice Address - Country:US
Practice Address - Phone:435-781-5746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT203926-4405364SP0809X
UT203926-8900364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult