Provider Demographics
NPI:1578578316
Name:DOCHTERMAN, CONNIE MARIE (APRN,BC)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:MARIE
Last Name:DOCHTERMAN
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Gender:F
Credentials:APRN,BC
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Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:CANTON-LAGRANGE FAMILY PRACTICE
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-0309
Mailing Address - Country:US
Mailing Address - Phone:573-288-5360
Mailing Address - Fax:573-288-5361
Practice Address - Street 1:1802 ELM ST
Practice Address - Street 2:CANTON-LAGRANGE FAMILY PRACTICE
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1694
Practice Address - Country:US
Practice Address - Phone:573-288-5360
Practice Address - Fax:573-288-5361
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2012-04-19
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Provider Licenses
StateLicense IDTaxonomies
MO100511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS76668Medicare UPIN