Provider Demographics
NPI:1518970177
Name:EBBINGHAUS, CONNIE MICHELE (CRNA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MICHELE
Last Name:EBBINGHAUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 S BRONZE MORN PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-7764
Mailing Address - Country:US
Mailing Address - Phone:520-731-2585
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-629-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN583236367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered