Provider Demographics
NPI:1932197977
Name:COUSINS, CONNIE (CRNA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:COUSINS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 FULLINGMILL RD
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:PA
Mailing Address - Zip Code:16137-2006
Mailing Address - Country:US
Mailing Address - Phone:724-699-5313
Mailing Address - Fax:724-662-9296
Practice Address - Street 1:334 FULLINGMILL RD
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137-2006
Practice Address - Country:US
Practice Address - Phone:724-699-5313
Practice Address - Fax:724-662-9296
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH113654367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0814766Medicaid
OHCO8229054Medicare ID - Type Unspecified