1336201052 NPI number — MRS. CONNIE DARLENE BAGLEY ARNP

Table of content: MRS. CONNIE DARLENE BAGLEY ARNP (NPI 1336201052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336201052 NPI number — MRS. CONNIE DARLENE BAGLEY ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGLEY
Provider First Name:
CONNIE
Provider Middle Name:
DARLENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336201052
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4652 VALLE DEL SOL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONSALL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92003-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-806-4870
Provider Business Mailing Address Fax Number:
760-806-4870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4652 VALLE DEL SOL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONSALL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92003-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-806-4870
Provider Business Practice Location Address Fax Number:
760-806-4870
Provider Enumeration Date:
12/16/2006

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: 363LA2200X , with the licence number:  17719 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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