Provider Demographics
NPI:1912208364
Name:CARPENTER, CONNIE RENA (RN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:RENA
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:R
Other - Last Name:LOGAN-HAZELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6104 OLD BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2518
Mailing Address - Country:US
Mailing Address - Phone:301-702-6235
Mailing Address - Fax:
Practice Address - Street 1:6104 OLD BRANCH AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-2518
Practice Address - Country:US
Practice Address - Phone:301-702-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR096203163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse