1578578316 NPI number — MS. CONNIE MARIE DOCHTERMAN APRN,BC

Table of content: MS. CONNIE MARIE DOCHTERMAN APRN,BC (NPI 1578578316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578578316 NPI number — MS. CONNIE MARIE DOCHTERMAN APRN,BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOCHTERMAN
Provider First Name:
CONNIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN,BC
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:
1578578316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 309
Provider Second Line Business Mailing Address:
CANTON-LAGRANGE FAMILY PRACTICE
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63435-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-288-5360
Provider Business Mailing Address Fax Number:
573-288-5361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 ELM ST
Provider Second Line Business Practice Location Address:
CANTON-LAGRANGE FAMILY PRACTICE
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63435-1694
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-288-5360
Provider Business Practice Location Address Fax Number:
573-288-5361
Provider Enumeration Date:
07/30/2006

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: 363LF0000X , with the licence number:  100511 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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