Provider Demographics
NPI:1184057044
Name:POMERANTZ, CONNIE FALCON (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:FALCON
Last Name:POMERANTZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:FALCON
Other - Last Name:DAUZAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:4311 CONSTELLATION AVE
Mailing Address - Street 2:UNIT G53
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-2735
Mailing Address - Country:US
Mailing Address - Phone:985-287-1416
Mailing Address - Fax:
Practice Address - Street 1:1301 HUFFMAN RD STE 100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3568
Practice Address - Country:US
Practice Address - Phone:907-345-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07377363LA2100X, 363LF0000X
AK1407363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1607051Medicaid