Provider Demographics
NPI:1205222924
Name:HARRIS, CONNIE LINNETTE
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LINNETTE
Last Name:HARRIS
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 1:1264 MOON VISION ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052
Mailing Address - Country:US
Mailing Address - Phone:701-491-1265
Mailing Address - Fax:702-453-8874
Practice Address - Street 1:1380 E SILVERADO RANCH BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-5924
Practice Address - Country:US
Practice Address - Phone:702-491-1265
Practice Address - Fax:702-453-8874
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1811262488Medicaid