Provider Demographics
NPI:1629136221
Name:RICHARDSON, CONNIE B (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:B
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180B DEBUYS RD
Mailing Address - Street 2:SUITE 223
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4404
Mailing Address - Country:US
Mailing Address - Phone:228-388-4862
Mailing Address - Fax:228-388-2556
Practice Address - Street 1:180B DEBUYS RD
Practice Address - Street 2:SUITE 223
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4404
Practice Address - Country:US
Practice Address - Phone:228-388-4862
Practice Address - Fax:228-388-2556
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR702226363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640654841OtherTRICARE FOR LIFE
MS00123168Medicaid
MS00123168Medicaid
MS500000749Medicare ID - Type Unspecified