Healthcare Provider Details

I. General information

NPI: 1376573626
Provider Name (Legal Business Name): CONNIE JO LARKIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 160/163 BUILDING KA2010 DHHS NAIHS PHS KAYENTA HEALTH CENTER
KAYENTA AZ
86033-0368
US

IV. Provider business mailing address

PO BOX 368
KAYENTA AZ
86033-0368
US

V. Phone/Fax

Practice location:
  • Phone: 928-697-4000
  • Fax: 928-697-4145
Mailing address:
  • Phone: 928-697-4000
  • Fax: 928-697-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-45252-102
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: