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NPI Code Detail

MEDICARE: MISS JADA RAE CONNALLY LAT

MEDICARE: MISS JADA RAE CONNALLY LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic TrainerAT4325TX

General Provider Information

NPI Number : 1689990822
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS JADA RAE CONNALLY LAT
Provider Business Mailing Address
First Line : 5510 RIO GRANDE AVE
Second Line :
City : MIDLAND
State : TX
Zip : 79707-9701
Country : US
Telephone Number : 318-564-0376
Fax Number :
Provider Business Practice Location Address
First Line : 5615 DEAUVILLE STE 220
Second Line :
City : MIDLAND
State : TX
Zip : 79706-2707
Country : US
Telephone Number : 432-221-4004
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/13/2010
Last Update Date : 05/08/2022

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Directions to “ MISS JADA RAE CONNALLY LAT” Practice Location

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