Provider Demographics
NPI:1891129672
Name:OLIVER, CONNIE
Entity Type:Individual
Prefix:MISS
First Name:CONNIE
Middle Name:
Last Name:OLIVER
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 1:510 N PASEO DE ONATE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2618
Mailing Address - Country:US
Mailing Address - Phone:505-753-3369
Mailing Address - Fax:505-753-4006
Practice Address - Street 1:510 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2618
Practice Address - Country:US
Practice Address - Phone:505-753-3369
Practice Address - Fax:505-753-4006
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7245225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist