Provider Demographics
NPI:1770657512
Name:WOLCOTT, CONNIE J (CNM)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:WOLCOTT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 N. 3855 EAST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442
Mailing Address - Country:US
Mailing Address - Phone:208-745-7571
Mailing Address - Fax:208-745-8924
Practice Address - Street 1:297 N. 3855 EAST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442
Practice Address - Country:US
Practice Address - Phone:208-745-7571
Practice Address - Fax:208-745-8924
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM-24A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806195000Medicaid