Provider Demographics
NPI:1891813879
Name:KNOWLTON, CONNIE LOU (RN)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LOU
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7900
Mailing Address - Street 2:14830 CHOATE CIRCLE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28241-7900
Mailing Address - Country:US
Mailing Address - Phone:704-587-1415
Mailing Address - Fax:704-587-1554
Practice Address - Street 1:14830 CHOATE CIRCLE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273
Practice Address - Country:US
Practice Address - Phone:704-587-1415
Practice Address - Fax:704-587-1554
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR103111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376556522OtherSIM USA INC NPI