=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790225969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE MCDONALD CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2017
-----------------------------------------------------
Last Update Date | 03/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 STATE ROUTE 522 UNIT 2
-----------------------------------------------------
City | WHEELERSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45694-8120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-574-8728
-----------------------------------------------------
Fax | 740-574-8918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 STATE ROUTE 522 UNIT 2
-----------------------------------------------------
City | WHEELERSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45694-8120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-574-8728
-----------------------------------------------------
Fax | 740-574-8918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.020430
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | ARNP 3011028
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------