Provider Demographics
NPI:1659508505
Name:PINE, CONNIE ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:ANN
Last Name:PINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8412 BRICK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9107
Mailing Address - Country:US
Mailing Address - Phone:740-255-7974
Mailing Address - Fax:
Practice Address - Street 1:8412 BRICK CHURCH RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9107
Practice Address - Country:US
Practice Address - Phone:740-255-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 120647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse