Provider Demographics
NPI:1043540651
Name:LANDRUM, CONNIE LOU (MD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:LOU
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2986
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362
Mailing Address - Country:US
Mailing Address - Phone:360-417-1027
Mailing Address - Fax:360-417-1028
Practice Address - Street 1:641 DIAMOND VISTA DR
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363
Practice Address - Country:US
Practice Address - Phone:360-417-1027
Practice Address - Fax:360-417-1028
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033643208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice