Provider Demographics
NPI:1285020354
Name:CONN, CARRIE (IDC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CONN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4981 CATOCTIN DR APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-2612
Mailing Address - Country:US
Mailing Address - Phone:757-374-9167
Mailing Address - Fax:
Practice Address - Street 1:4981 CATOCTIN DR APT 6
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2612
Practice Address - Country:US
Practice Address - Phone:757-374-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman