Provider Demographics
NPI:1407140569
Name:WARD, CONNIE JIN (APN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JIN
Last Name:WARD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3219
Mailing Address - Country:US
Mailing Address - Phone:479-314-4757
Mailing Address - Fax:479-314-1194
Practice Address - Street 1:7001 ROGERS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4073
Practice Address - Country:US
Practice Address - Phone:479-314-7490
Practice Address - Fax:479-314-7494
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03542363LA2200X
ARR73205363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA03542OtherLICENSURE
ARR73205OtherLICENSURE