1710968300 NPI number — MRS. TINA ANNETTE CONNALLY RN

Table of content: (NPI 1699870105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710968300 NPI number — MRS. TINA ANNETTE CONNALLY RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNALLY
Provider First Name:
TINA
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
TINA
Provider Other Middle Name:
ANNETTE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710968300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18TH MEDCOM
Provider Second Line Business Mailing Address:
ATTN: DCCS-QM (CREDENTIALS)
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96205-0054
Provider Business Mailing Address Country Code:
KR
Provider Business Mailing Address Telephone Number:
01182279166027
Provider Business Mailing Address Fax Number:
01182279178110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HHC, 121ST GENERAL HOSPITAL
Provider Second Line Business Practice Location Address:
ATTN: DON/ICU
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96205
Provider Business Practice Location Address Country Code:
KR
Provider Business Practice Location Address Telephone Number:
01182279175068
Provider Business Practice Location Address Fax Number:
01182279173000
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  R28975 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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