Provider Demographics
NPI:1144213109
Name:HARTLEY, CONNIE L (APRN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:LYNN
Other - Last Name:CROSSLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1950 LAUREL MANOR DR
Mailing Address - Street 2:STE 224
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5602
Mailing Address - Country:US
Mailing Address - Phone:352-751-6565
Mailing Address - Fax:352-205-7777
Practice Address - Street 1:1950 LAUREL MANOR DR
Practice Address - Street 2:STE 224
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5602
Practice Address - Country:US
Practice Address - Phone:352-751-6565
Practice Address - Fax:352-205-7777
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9168770363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304789000Medicaid
FLE4430YMedicare ID - Type Unspecified
FL304789000Medicaid