Provider Demographics
NPI:1760010391
Name:DOUGLAS, CONNIE MARIE
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
Last Name:DOUGLAS
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 1:15216 FM 1887 RD
Mailing Address - Street 2:15216 FM 1887 RD
Mailing Address - City:HEMPSTEAD
Mailing Address - State:TX
Mailing Address - Zip Code:77445
Mailing Address - Country:US
Mailing Address - Phone:832-788-0220
Mailing Address - Fax:
Practice Address - Street 1:15216 FM 1887 RD
Practice Address - Street 2:15216 FM 1887 RD
Practice Address - City:HEMPSTEAD
Practice Address - State:TX
Practice Address - Zip Code:77445
Practice Address - Country:US
Practice Address - Phone:832-788-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider