Provider Demographics
NPI:1255789178
Name:MCCONNELL, ADDISON BAILIE (BA)
Entity type:Individual
Prefix:MRS
First Name:ADDISON
Middle Name:BAILIE
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:ADDISON
Other - Middle Name:BALIE
Other - Last Name:GUTHRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:904 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1653
Mailing Address - Country:US
Mailing Address - Phone:918-571-2470
Mailing Address - Fax:
Practice Address - Street 1:904 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1653
Practice Address - Country:US
Practice Address - Phone:918-571-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK860051454253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200507310 AMedicaid
OK100733860 BMedicaid