Provider Demographics
NPI:1952751497
Name:NORTHCUTT, CONSWALIS L (NP)
Entity Type:Individual
Prefix:
First Name:CONSWALIS
Middle Name:L
Last Name:NORTHCUTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 RUSSELL PKWY
Mailing Address - Street 2:BLDG 700
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5763
Mailing Address - Country:US
Mailing Address - Phone:478-328-7674
Mailing Address - Fax:478-328-1393
Practice Address - Street 1:1719 RUSSELL PKWY
Practice Address - Street 2:BLDG 700
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5763
Practice Address - Country:US
Practice Address - Phone:478-328-7674
Practice Address - Fax:478-328-1393
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203938363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN203938OtherNURSE PRACTIONER LICENSURE NUMBER
GAAG0815122OtherCERTIFICATION NUMBER (AMERICAN ACADEMY OF NURSE PRACTITIONERS)