Provider Demographics
NPI:1679079875
Name:DIXON, CONNIE FAYE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:FAYE
Last Name:DIXON
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 1:4447 FM RD 2661
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:74704
Mailing Address - Country:US
Mailing Address - Phone:903-521-5606
Mailing Address - Fax:
Practice Address - Street 1:4447 FM RD 2661
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:74704
Practice Address - Country:US
Practice Address - Phone:903-521-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX606424163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse