Provider Demographics
NPI:1184830473
Name:NELLUM, CONNIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:NELLUM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 S LOOP 12 # 202B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-6607
Mailing Address - Country:US
Mailing Address - Phone:214-398-4157
Mailing Address - Fax:214-398-4326
Practice Address - Street 1:909 MORRISON DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6079
Practice Address - Country:US
Practice Address - Phone:214-398-4157
Practice Address - Fax:214-398-4326
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX528675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily