{
"Npi": {
"NPI": "1710968300",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "X",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "CONNALLY",
"FirstName": "TINA",
"MiddleName": "ANNETTE",
"NamePrefix": "MRS.",
"NameSuffix": null,
"Credential": "RN",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "JOHNSON",
"OtherFirstName": "TINA",
"OtherMiddleName": "ANNETTE",
"OtherNamePrefix": "MISS",
"OtherNameSuffix": null,
"OtherCredential": "RN",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "18TH MEDCOM",
"SecondLineMailingAddress": "ATTN: DCCS-QM (CREDENTIALS)",
"MailingAddressCityName": "APO",
"MailingAddressStateName": "AP",
"MailingAddressPostalCode": "96205-0054",
"MailingAddressCountryCode": "KR",
"MailingAddressTelephoneNumber": "01182279166027",
"MailingAddressFaxNumber": "01182279178110",
"FirstLinePracticeLocationAddress": "HHC, 121ST GENERAL HOSPITAL",
"SecondLinePracticeLocationAddress": "ATTN: DON/ICU",
"PracticeLocationAddressCityName": "APO",
"PracticeLocationAddressStateName": "AP",
"PracticeLocationAddressPostalCode": "96205",
"PracticeLocationAddressCountryCode": "KR",
"PracticeLocationAddressTelephoneNumber": "01182279175068",
"PracticeLocationAddressFaxNumber": "01182279173000",
"EnumerationDate": "11/10/2005",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "163W00000X",
"TaxonomyName": "Registered Nurse",
"LicenseNumber": "R28975",
"LicenseNumberStateCode": "NM",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}