Provider Demographics
NPI:1558917542
Name:MECKLEY, CONNIE JEAN
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JEAN
Last Name:MECKLEY
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 1:4112 E WEAVER PL
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-3256
Mailing Address - Country:US
Mailing Address - Phone:303-770-0858
Mailing Address - Fax:
Practice Address - Street 1:4112 E WEAVER PL
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80121-3256
Practice Address - Country:US
Practice Address - Phone:303-770-0858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant