Provider Demographics
NPI:1083094239
Name:STROUSE, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:STROUSE
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 1:61 PARK DR APT 8
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5206
Mailing Address - Country:US
Mailing Address - Phone:630-653-4231
Mailing Address - Fax:
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326
Practice Address - Country:US
Practice Address - Phone:928-639-6172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ56206207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program