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NPI Code Detail

MEDICARE: CONNIE E DEDMON PNP

MEDICARE: CONNIE E DEDMON PNP
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
1363LP0200XPediatric Nurse Practitioner230593TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11750369203OTHERGROUP NPI
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1467437954
Entity Type Code : Individual
Provider Name (Legal Business Name) : CONNIE E DEDMON PNP
Provider Business Mailing Address
First Line : PO BOX 99371
Second Line :
City : FORT WORTH
State : TX
Zip : 76199-0371
Country : US
Telephone Number : 682-885-1855
Fax Number : 682-885-7347
Provider Business Practice Location Address
First Line : 4405 RIVER OAKS BLVD
Second Line :
City : FORT WORTH
State : TX
Zip : 76114-2326
Country : US
Telephone Number : 817-624-1770
Fax Number : 817-625-1287
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/07/2005
Last Update Date : 04/03/2012

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Directions to “ CONNIE E DEDMON PNP” Practice Location

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