Provider Demographics
NPI:1790751642
Name:HALE, CONNIE (NP)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:HALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 PICCADILLY CIR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-7127
Mailing Address - Country:US
Mailing Address - Phone:318-422-4620
Mailing Address - Fax:
Practice Address - Street 1:3018 OLD MINDEN RD STE 1117
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2497
Practice Address - Country:US
Practice Address - Phone:318-746-1935
Practice Address - Fax:318-746-2514
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP038322084P0802X, 276400000X, 283Q00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No283Q00000XHospitalsPsychiatric Hospital
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1189537Medicaid
LA1189537Medicaid
P37089Medicare UPIN