Healthcare Provider Details

I. General information

NPI: 1164990131
Provider Name (Legal Business Name): ARIEL GRACE CONNERS PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 710
CHICAGO IL
60612-3863
US

IV. Provider business mailing address

19117 MARBLE GLEN LN
PFLUGERVILLE TX
78660-3593
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-3034
  • Fax: 312-563-2519
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP138356
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number041-470175
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: