Provider Demographics
NPI:1003536426
Name:IDLAND, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:IDLAND
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:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-0725
Mailing Address - Country:US
Mailing Address - Phone:406-974-2294
Mailing Address - Fax:
Practice Address - Street 1:502 1ST ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:ND
Practice Address - Zip Code:58853-4052
Practice Address - Country:US
Practice Address - Phone:406-974-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant