Provider Demographics
NPI:1710357934
Name:DELONGCHAMP, CONNIE JO
Entity Type:Individual
Prefix:
First Name:CONNIE JO
Middle Name:
Last Name:DELONGCHAMP
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 1:3301 N BALLARD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8928
Mailing Address - Country:US
Mailing Address - Phone:920-733-4443
Mailing Address - Fax:920-733-4796
Practice Address - Street 1:3301 N BALLARD RD
Practice Address - Street 2:SUITE B
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8980
Practice Address - Country:US
Practice Address - Phone:920-733-4443
Practice Address - Fax:920-733-4796
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI319760164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse